Provider Demographics
NPI:1518179191
Name:ROUBICEK & SHAW
Entity Type:Organization
Organization Name:ROUBICEK & SHAW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:CLARK
Authorized Official - Last Name:ROUBICEK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LCSW
Authorized Official - Phone:559-323-8484
Mailing Address - Street 1:1879 E FIR AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3841
Mailing Address - Country:US
Mailing Address - Phone:559-323-8484
Mailing Address - Fax:559-323-8686
Practice Address - Street 1:1879 E FIR AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3841
Practice Address - Country:US
Practice Address - Phone:559-323-8484
Practice Address - Fax:559-323-8686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA158111041C0700X
CA43024106H00000X
CA42972106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ155151ZMedicare ID - Type Unspecified