Provider Demographics
NPI:1871612994
Name:LACKOVIC, ANDREA (PSYD)
Entity type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:
Last Name:LACKOVIC
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8800
Mailing Address - Street 2:
Mailing Address - City:CORCORAN
Mailing Address - State:CA
Mailing Address - Zip Code:93212-8800
Mailing Address - Country:US
Mailing Address - Phone:559-992-8800
Mailing Address - Fax:
Practice Address - Street 1:4001 KING AVE
Practice Address - Street 2:
Practice Address - City:CORCORAN
Practice Address - State:CA
Practice Address - Zip Code:93212-9611
Practice Address - Country:US
Practice Address - Phone:559-992-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY23544103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY23544OtherCA LICENSE NUMBER