Healthcare Provider Details

I. General information

NPI: 1205935889
Provider Name (Legal Business Name): BRUCE DANIEL KOBAL PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 04/28/2023
Certification Date: 04/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3939 W RIDGE RD # B47
ERIE PA
16506-1879
US

IV. Provider business mailing address

3939 W RIDGE RD # B47
ERIE PA
16506-1879
US

V. Phone/Fax

Practice location:
  • Phone: 814-923-8140
  • Fax: 814-315-6044
Mailing address:
  • Phone: 814-923-8410
  • Fax: 814-315-6044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS006269L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: