Provider Demographics
NPI:1194708537
Name:REHAK, ROBERT W JR (LCSW)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:REHAK
Suffix:JR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:642 DAMERON DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-2411
Mailing Address - Country:US
Mailing Address - Phone:928-445-5211
Mailing Address - Fax:928-776-8484
Practice Address - Street 1:642 DAMERON DR
Practice Address - Street 2:HILLSIDE CLINIC
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-2411
Practice Address - Country:US
Practice Address - Phone:928-445-5211
Practice Address - Fax:928-776-8484
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW1317104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker