Provider Demographics
NPI:1023199536
Name:MAYES, ROBERT LEE
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:LEE
Last Name:MAYES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10174 OLD GROVE ROAD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131
Mailing Address - Country:US
Mailing Address - Phone:858-444-8823
Mailing Address - Fax:858-444-8827
Practice Address - Street 1:10174 OLD GROVE RD STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92131-1652
Practice Address - Country:US
Practice Address - Phone:858-444-8823
Practice Address - Fax:858-444-8827
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2017-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-15-02677106S00000X
101YM0800X, 373H00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist