Provider Demographics
NPI:1851583769
Name:BOYACK, ROBERT E
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:E
Last Name:BOYACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91-1841 FORT WEAVER RD
Mailing Address - Street 2:
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-1909
Mailing Address - Country:US
Mailing Address - Phone:808-681-3500
Mailing Address - Fax:
Practice Address - Street 1:91-1841 FORT WEAVER RD
Practice Address - Street 2:
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-1909
Practice Address - Country:US
Practice Address - Phone:808-681-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW 28461041C0700X
HI1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical