Provider Demographics
NPI:1154917052
Name:PETTIBONE, ROBERT (BCBA)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:PETTIBONE
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4719 S CALHOUN ST
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46807-2811
Mailing Address - Country:US
Mailing Address - Phone:260-705-0522
Mailing Address - Fax:
Practice Address - Street 1:4719 S CALHOUN ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46807-2811
Practice Address - Country:US
Practice Address - Phone:260-705-0522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-15
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1-19-40238103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst