Provider Demographics
NPI:1043519150
Name:OWENS, ABDUL RAHIM I
Entity Type:Individual
Prefix:MR
First Name:ABDUL
Middle Name:RAHIM
Last Name:OWENS
Suffix:I
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:ABDUL
Other - Middle Name:RAHIM
Other - Last Name:OWENS
Other - Suffix:I
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4368 LINCOLN AVE
Mailing Address - Street 2:4368 LINCOLN
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94602-2529
Mailing Address - Country:US
Mailing Address - Phone:510-531-3111
Mailing Address - Fax:510-530-8083
Practice Address - Street 1:4368 LINCOLN AVE
Practice Address - Street 2:4368 LINCOLN
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94602-2529
Practice Address - Country:US
Practice Address - Phone:510-531-3111
Practice Address - Fax:510-530-8083
Is Sole Proprietor?:No
Enumeration Date:2011-03-16
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB6731917101YM0800X, 101Y00000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5BASEBALLOtherMEDI-CAL