Provider Demographics
NPI:1639553811
Name:LICHTENTHAL, ROBERT (IMH)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:LICHTENTHAL
Suffix:
Gender:M
Credentials:IMH
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 16
Mailing Address - Street 2:
Mailing Address - City:HOLDER
Mailing Address - State:FL
Mailing Address - Zip Code:34445-0016
Mailing Address - Country:US
Mailing Address - Phone:352-697-5942
Mailing Address - Fax:352-228-8901
Practice Address - Street 1:116 NE 5TH ST
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-4150
Practice Address - Country:US
Practice Address - Phone:352-228-4969
Practice Address - Fax:352-228-8901
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-16
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH13661101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health