Provider Demographics
NPI:1538943790
Name:LACKEY, MADISON GREER (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:MADISON
Middle Name:GREER
Last Name:LACKEY
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2689 OAKVILLE PLANTATION RD
Mailing Address - Street 2:
Mailing Address - City:JOHNS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29455-4619
Mailing Address - Country:US
Mailing Address - Phone:843-303-0270
Mailing Address - Fax:
Practice Address - Street 1:505 IRVIN CT STE 101
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1780
Practice Address - Country:US
Practice Address - Phone:404-297-0821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT016681225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist