MEDICARE: ROBERT PETTIBONE BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	1-19-40238	IN

General Provider Information

NPI Number	:	1154917052
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT PETTIBONE BCBA

Provider Business Mailing Address
First Line	:	4719 S CALHOUN ST
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46807-2811
Country	:	US
Telephone Number	:	260-705-0522
Fax Number	:

Provider Business Practice Location Address
First Line	:	4719 S CALHOUN ST
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46807-2811
Country	:	US
Telephone Number	:	260-705-0522
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/15/2020
Last Update Date	:	08/13/2021

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