Provider Demographics
NPI:1275830010
Name:KACICK, LYNDON ROBERT (LAC)
Entity Type:Individual
Prefix:
First Name:LYNDON
Middle Name:ROBERT
Last Name:KACICK
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 S 10TH ST
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:MT
Mailing Address - Zip Code:59047-3710
Mailing Address - Country:US
Mailing Address - Phone:406-223-3864
Mailing Address - Fax:
Practice Address - Street 1:517 S 10TH ST
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:MT
Practice Address - Zip Code:59047-3710
Practice Address - Country:US
Practice Address - Phone:406-223-3864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-14
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1250101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)