Provider Demographics
NPI:1366220212
Name:ROBAK, SHAYNE R
Entity type:Individual
Prefix:
First Name:SHAYNE
Middle Name:R
Last Name:ROBAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHAYNE
Other - Middle Name:R
Other - Last Name:GRAFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1169 POQUONNOCK RD
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-4620
Mailing Address - Country:US
Mailing Address - Phone:719-766-1005
Mailing Address - Fax:
Practice Address - Street 1:19 CLEMENT ST
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385-3003
Practice Address - Country:US
Practice Address - Phone:719-766-1005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-20
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2085103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst