Healthcare Provider Details

I. General information

NPI: 1740697523
Provider Name (Legal Business Name): HEIDI LACK, PHD, ATR-BC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2014
Last Update Date: 07/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 CLARKE ST STE 23
LEXINGTON MA
02421-4938
US

IV. Provider business mailing address

16 CLARKE ST STE 23
LEXINGTON MA
02421-4938
US

V. Phone/Fax

Practice location:
  • Phone: 781-863-8696
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number7518
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number7518
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number7518
License Number StateMA

VIII. Authorized Official

Name: DR. HEIDI LACK
Title or Position: DIRECTOR, PSYCHOLOGISTART THERAPIST
Credential: PHD, ATR-BC
Phone: 781-863-8696