Healthcare Provider Details

I. General information

NPI: 1902022320
Provider Name (Legal Business Name): ROBERT E THACKER JR. MA, IAADC,SAP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 08/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 S. WALNUT AVE.
AMES IA
50010
US

IV. Provider business mailing address

223 S. WALNUT AVE.
AMES IA
50010
US

V. Phone/Fax

Practice location:
  • Phone: 515-233-1122
  • Fax: 515-233-6500
Mailing address:
  • Phone: 515-233-1122
  • Fax: 515-233-6500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number10159
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: