Provider Demographics
NPI:1447309216
Name:ROBERTS, EILEEN DENISE (PHD)
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:DENISE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:EILEEN
Other - Middle Name:
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:1123 S CLOVERDALE BLVD # 112
Mailing Address - Street 2:
Mailing Address - City:CLOVERDALE
Mailing Address - State:CA
Mailing Address - Zip Code:95425-4402
Mailing Address - Country:US
Mailing Address - Phone:707-867-6635
Mailing Address - Fax:
Practice Address - Street 1:1123 S CLOVERDALE BLVD # 112
Practice Address - Street 2:
Practice Address - City:CLOVERDALE
Practice Address - State:CA
Practice Address - Zip Code:95425-4402
Practice Address - Country:US
Practice Address - Phone:707-867-6635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY21286103TC0700X
CAPSY21296103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL75153Medicare ID - Type Unspecified