Provider Demographics
NPI:1659103943
Name:IANNACE, ROBERT JR (LAC, NCC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:IANNACE
Suffix:JR
Gender:M
Credentials:LAC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 PARTRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08003-1950
Mailing Address - Country:US
Mailing Address - Phone:215-554-0837
Mailing Address - Fax:
Practice Address - Street 1:4551 BLACK HORSE PIKE
Practice Address - Street 2:
Practice Address - City:BLACKWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08012-1751
Practice Address - Country:US
Practice Address - Phone:856-981-9905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-15
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00809900101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty