Provider Demographics
NPI:1740697523
Name:HEIDI LACK, PHD, ATR-BC
Entity type:Organization
Organization Name:HEIDI LACK, PHD, ATR-BC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, PSYCHOLOGISTART THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:
Authorized Official - Last Name:LACK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, ATR-BC
Authorized Official - Phone:781-863-8696
Mailing Address - Street 1:16 CLARKE ST STE 23
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02421-4938
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16 CLARKE ST STE 23
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02421-4938
Practice Address - Country:US
Practice Address - Phone:781-863-8696
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-14
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7518261QM0801X, 261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health