Provider Demographics
NPI:1245403401
Name:BECKER, ROBERT N (MA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:N
Last Name:BECKER
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:655 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IN
Mailing Address - Zip Code:46970-2662
Mailing Address - Country:US
Mailing Address - Phone:765-472-1931
Mailing Address - Fax:765-472-1945
Practice Address - Street 1:655 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-2662
Practice Address - Country:US
Practice Address - Phone:765-472-1931
Practice Address - Fax:765-472-1945
Is Sole Proprietor?:No
Enumeration Date:2008-04-09
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INC1179101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
INC1179OtherCADAC I