Provider Demographics
NPI:1831359926
Name:CARMIGNANI, ROBERT PETER (PHD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:PETER
Last Name:CARMIGNANI
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 1:17194 FITZPATRICK LN
Mailing Address - Street 2:
Mailing Address - City:OCCIDENTAL
Mailing Address - State:CA
Mailing Address - Zip Code:95465-9353
Mailing Address - Country:US
Mailing Address - Phone:707-874-2524
Mailing Address - Fax:
Practice Address - Street 1:250 BEL MARIN KEYS BLVD STE C3
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94949-5708
Practice Address - Country:US
Practice Address - Phone:415-639-9908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-11
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY4139103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABH614AMedicare PIN