=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922356906
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACTION COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2012
-----------------------------------------------------
Last Update Date | 08/21/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1010 E BRUNEAU AVE
-----------------------------------------------------
City | KENNEWICK
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99336-3775
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-735-7410
-----------------------------------------------------
Fax | 509-783-5953
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 5697
-----------------------------------------------------
City | KENNEWICK
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99336-0697
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-735-7410
-----------------------------------------------------
Fax | 509-783-5953
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. ROBERT G LACK
-----------------------------------------------------
Credential | MA, CDP, CL
-----------------------------------------------------
Telephone | 509-735-7410
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 03060500
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------