Provider Demographics
NPI:1184917593
Name:BUMBACO, ROBERT (LCSW)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:BUMBACO
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 1:10475 PERRY HWY STE 300
Mailing Address - Street 2:
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-9213
Mailing Address - Country:US
Mailing Address - Phone:724-759-7500
Mailing Address - Fax:724-759-7600
Practice Address - Street 1:10475 PERRY HWY STE 300
Practice Address - Street 2:
Practice Address - City:WEXFORD
Practice Address - State:PA
Practice Address - Zip Code:15090-9213
Practice Address - Country:US
Practice Address - Phone:724-759-7500
Practice Address - Fax:724-759-7600
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-17
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0180231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008032021Medicaid
CT004082286Medicaid
CT008022626Medicaid
CT008032021Medicaid