Provider Demographics
NPI:1083255798
Name:NOVACK, ROBERT DAVID (AMFT APCC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:DAVID
Last Name:NOVACK
Suffix:
Gender:M
Credentials:AMFT APCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2138
Mailing Address - Street 2:
Mailing Address - City:RAMONA
Mailing Address - State:CA
Mailing Address - Zip Code:92065-0936
Mailing Address - Country:US
Mailing Address - Phone:925-548-5206
Mailing Address - Fax:
Practice Address - Street 1:409 CAMINO DEL RIO S STE 201
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3505
Practice Address - Country:US
Practice Address - Phone:619-346-4020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-03
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA125841106H00000X
CA9597101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist