Provider Demographics
NPI:1346306990
Name:ROBACK, MICHAEL EDWARD (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:EDWARD
Last Name:ROBACK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 N KENTER AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-2338
Mailing Address - Country:US
Mailing Address - Phone:310-472-3385
Mailing Address - Fax:310-472-3386
Practice Address - Street 1:921 WESTWOOD BLVD
Practice Address - Street 2:SUITE 217
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-2944
Practice Address - Country:US
Practice Address - Phone:310-472-3385
Practice Address - Fax:310-472-3386
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS117151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical