Active NPI
Robert Pettibone, BCBA
- Behavior Analyst
- Fort Wayne, IN
National Provider Identifier
1154917052
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Behavior Analyst
- License
- 1-19-40238
- Practice address
- 4719 S Calhoun St
Fort Wayne, IN 46807-2811 - Phone
- (260) 705-0522
- NPI assigned
- Dec 15, 2020
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Behavior Analyst | 103K00000X | 1-19-40238 | IN | Primary |
Addresses
Primary practice location
4719 S Calhoun St
Fort Wayne, IN 46807-2811
Mailing address
4719 S Calhoun St
Fort Wayne, IN 46807-2811
Phone (260) 705-0522
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1607990400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1628812800000",
"number": "1154917052",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4719 S CALHOUN ST",
"city": "FORT WAYNE",
"state": "IN",
"postal_code": "468072811",
"telephone_number": "260-705-0522"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4719 S CALHOUN ST",
"city": "FORT WAYNE",
"state": "IN",
"postal_code": "468072811",
"telephone_number": "260-705-0522"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PETTIBONE",
"first_name": "ROBERT",
"credential": "BCBA",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2020-12-15",
"last_updated": "2021-08-13",
"certification_date": "2021-08-13",
"status": "A"
},
"taxonomies": [
{
"code": "103K00000X",
"taxonomy_group": "",
"desc": "Behavior Analyst",
"state": "IN",
"license": "1-19-40238",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Fort Wayne, IN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 13, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.