Provider Demographics
NPI:1932683323
Name:IBRAHAM, ROBERT MICHAEL (JD, PHD, CASAC-M/G)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:MICHAEL
Last Name:IBRAHAM
Suffix:
Gender:M
Credentials:JD, PHD, CASAC-M/G
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 TROUT ST
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11769-1529
Mailing Address - Country:US
Mailing Address - Phone:631-589-9500
Mailing Address - Fax:631-647-3130
Practice Address - Street 1:220 VETERANS MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788-2420
Practice Address - Country:US
Practice Address - Phone:631-406-5518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-20
Last Update Date:2025-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY34794101YA0400X
NYP128122103TA0400X, 103TP2701X, 103TC0700X
103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical