| Doctor Name: | DR. CALEB WAYNE LACK |
| NPI Number: | 1003074741 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | PH.D. |
| License Number: | 07-37P |
| Business Practice Address: | 1110 W B St Suite H Russellville, AR - 728013506 |
| Business Phone Number: | 4796923702 |
| Business Fax Number: | |
| Mailing Address: | 1110 W B St, Suite H RUSSELLVILLE |
| State: | AR |
| Postal Code: | 728013506 |
| Phone Number: | 4796923702 |
| Fax Number: | |
| NPI Enumeration Date: | 05/29/2008 |
| NPI Last Update Date: | 05/29/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 103TC0700X |
| License Number: | 07-37P |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | AR |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Psychologist |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | |