Healthcare Provider Details

I. General information

NPI: 1134156961
Provider Name (Legal Business Name): ROBERT J LACKIE MS MA ATR LPC MFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 10/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6806 W 83RD ST BROADMOOR MEDICAL BUILDING
OVERLAND PARK KS
66204-3956
US

IV. Provider business mailing address

6221 W 121ST TER
OVERLAND PARK KS
66209-2576
US

V. Phone/Fax

Practice location:
  • Phone: 913-963-6850
  • Fax:
Mailing address:
  • Phone: 913-469-6179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1881
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number14871
License Number StateKS
# 4
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number14871
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number113957
License Number StateKS
# 6
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number113957
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: