Provider Demographics
NPI:1780384180
Name:IMBODEN, ROBERT MARC JR (LAC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:MARC
Last Name:IMBODEN
Suffix:JR
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 MISSISSIPPI ST S
Mailing Address - Street 2:
Mailing Address - City:WYNNE
Mailing Address - State:AR
Mailing Address - Zip Code:72396-3025
Mailing Address - Country:US
Mailing Address - Phone:870-208-8499
Mailing Address - Fax:
Practice Address - Street 1:204 MISSISSIPPI ST S
Practice Address - Street 2:
Practice Address - City:WYNNE
Practice Address - State:AR
Practice Address - Zip Code:72396-3025
Practice Address - Country:US
Practice Address - Phone:870-204-8499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-06
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA2409013101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health