Basic Information
Provider Information | |||||||||
NPI: | 1265733026 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | EUBANK | ||||||||
FirstName: | ROBYN | ||||||||
MiddleName: | N. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | HSPP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3645 N BRIARWOOD LN | ||||||||
Address2: | STE A | ||||||||
City: | MUNCIE | ||||||||
State: | IN | ||||||||
PostalCode: | 473045337 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7652895520 | ||||||||
FaxNumber: | 7652895840 | ||||||||
Practice Location | |||||||||
Address1: | 3700 W KILGORE AVE | ||||||||
Address2: |   | ||||||||
City: | MUNCIE | ||||||||
State: | IN | ||||||||
PostalCode: | 473044810 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7652895437 | ||||||||
FaxNumber: | 7652135094 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/10/2010 | ||||||||
LastUpdateDate: | 06/14/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TH0100X | 20042451A | IN | Y |   | Behavioral Health & Social Service Providers | Psychologist | Health Service |
ID Information
ID | Type | State | Issuer | Description | 201002290 | 05 | IN |   | MEDICAID |