Provider Demographics
NPI:1891578720
Name:KOBAK, BRIAN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:KOBAK
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:823 PARK EAST BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-0811
Mailing Address - Country:US
Mailing Address - Phone:765-297-0975
Mailing Address - Fax:
Practice Address - Street 1:823 PARK EAST BLVD STE B
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-0811
Practice Address - Country:US
Practice Address - Phone:765-297-0975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-15
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05015190A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist