Individual
MR. LEE TODD LACKS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
LCPC-C, MT-BC
Contact information
Practice address
9 LEMONT AVE, SOUTH PORTLAND, ME 04106-5717
(207) 210-6045
Mailing address
9 LEMONT AVE, SOUTH PORTLAND, ME 04106-5717
Taxonomy
Speciality
Code
Description
License number
State
251C00000X
Developmentally Disabled Services Day Training Agency
XL3782
ME
251S00000X
Community/Behavioral Health Agency
Primary
XL3782
ME
Other
Enumeration date
10/06/2011
Last updated
10/06/2011
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