Provider Demographics
NPI:1972841484
Name:RACKHAM, FORREST (PSYD)
Entity Type:Individual
Prefix:
First Name:FORREST
Middle Name:
Last Name:RACKHAM
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575B BLUES LAKE PKWY
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-8587
Mailing Address - Country:US
Mailing Address - Phone:573-364-2007
Mailing Address - Fax:573-202-2402
Practice Address - Street 1:575B BLUES LAKE PKWY
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-8587
Practice Address - Country:US
Practice Address - Phone:573-364-2007
Practice Address - Fax:573-202-2402
Is Sole Proprietor?:No
Enumeration Date:2013-01-18
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810004701103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical