Provider Demographics
NPI:1134156961
Name:LACKIE, ROBERT J (MS MA ATR LPC MFT)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:J
Last Name:LACKIE
Suffix:
Gender:M
Credentials:MS MA ATR LPC MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6221 W 121ST TER
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66209-2576
Mailing Address - Country:US
Mailing Address - Phone:913-469-6179
Mailing Address - Fax:
Practice Address - Street 1:6806 W 83RD ST
Practice Address - Street 2:BROADMOOR MEDICAL BUILDING
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66204-3956
Practice Address - Country:US
Practice Address - Phone:913-963-6850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1881101YM0800X
MO101YM0800X
KS14871221700000X
MO14871221700000X
KS113957106H00000X
MO113957106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist