Provider Demographics
NPI:1902022320
Name:THACKER, ROBERT E JR (MA, IAADC,SAP)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:E
Last Name:THACKER
Suffix:JR
Gender:M
Credentials:MA, IAADC,SAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 S. WALNUT AVE.
Mailing Address - Street 2:
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50010
Mailing Address - Country:US
Mailing Address - Phone:515-233-1122
Mailing Address - Fax:515-233-6500
Practice Address - Street 1:223 S. WALNUT AVE.
Practice Address - Street 2:
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50010
Practice Address - Country:US
Practice Address - Phone:515-233-1122
Practice Address - Fax:515-233-6500
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA10159101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)