Provider Demographics
NPI:1093308942
Name:ROBERTS, ABIA-IMO EYIRE
Entity Type:Individual
Prefix:MR
First Name:ABIA-IMO
Middle Name:EYIRE
Last Name:ROBERTS
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 1:1816 SCENIC AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94709-1324
Mailing Address - Country:US
Mailing Address - Phone:510-548-7270
Mailing Address - Fax:
Practice Address - Street 1:1765 LE ROY AVE APT A
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94709-1162
Practice Address - Country:US
Practice Address - Phone:510-944-7177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-11
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)