Provider Demographics
NPI:1780307926
Name:BOBB (S), LAURA MAE
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:MAE
Last Name:BOBB (S)
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5945 LISKA LN APT 112
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95119-1118
Mailing Address - Country:US
Mailing Address - Phone:669-338-8078
Mailing Address - Fax:
Practice Address - Street 1:1200 CONCORD AVE STE 185
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-5006
Practice Address - Country:US
Practice Address - Phone:650-648-4170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-22
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program