Provider Demographics
NPI:1154678100
Name:ROBERTS, EMMANUEL MARIANO (LMFT)
Entity Type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:MARIANO
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11878 AVENUE OF INDUSTRY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-3423
Mailing Address - Country:US
Mailing Address - Phone:858-487-3200
Mailing Address - Fax:858-485-5418
Practice Address - Street 1:11878 AVENUE OF INDUSTRY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-3423
Practice Address - Country:US
Practice Address - Phone:858-675-4230
Practice Address - Fax:858-753-1178
Is Sole Proprietor?:No
Enumeration Date:2012-08-09
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF79666106H00000X
390200000X
CALMFT109330106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program