Provider Demographics
NPI:1326716689
Name:BOBACK, ROBERT (LADC)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:BOBACK
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 LEWIS DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-1920
Mailing Address - Country:US
Mailing Address - Phone:203-694-9895
Mailing Address - Fax:
Practice Address - Street 1:76 LEWIS DR
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-1920
Practice Address - Country:US
Practice Address - Phone:203-694-9895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT44.001421101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)