Provider Demographics
NPI:1073912663
Name:FLACK, DALE
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:
Last Name:FLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 VICTORY PKWY
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45206-2882
Mailing Address - Country:US
Mailing Address - Phone:513-872-8870
Mailing Address - Fax:513-872-8873
Practice Address - Street 1:2200 VICTORY PKWY
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45206-2882
Practice Address - Country:US
Practice Address - Phone:513-872-8870
Practice Address - Fax:513-872-8873
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-19
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS--21585101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor