Provider Demographics
NPI:1205935889
Name:KOBAL, BRUCE DANIEL (PHD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:DANIEL
Last Name:KOBAL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3939 W RIDGE RD # B47
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-1879
Mailing Address - Country:US
Mailing Address - Phone:814-923-8410
Mailing Address - Fax:814-315-6044
Practice Address - Street 1:3939 W RIDGE RD # B47
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506-1879
Practice Address - Country:US
Practice Address - Phone:814-923-8140
Practice Address - Fax:814-315-6044
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS006269L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA114436OtherVALUEOPTIONS
PA000505965OtherHIMARK BC/BS