Provider Demographics
NPI:1386877389
Name:LACK, ROBERT GLENN III (MA, CDP)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:GLENN
Last Name:LACK
Suffix:III
Gender:M
Credentials:MA, CDP
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 5697
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-0697
Mailing Address - Country:US
Mailing Address - Phone:509-735-7410
Mailing Address - Fax:509-783-5953
Practice Address - Street 1:1010 E BRUNEAU AVE
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-3775
Practice Address - Country:US
Practice Address - Phone:509-735-7410
Practice Address - Fax:509-783-5953
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-25
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC-00018500101Y00000X
WACP-00001417101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor