Provider Demographics
NPI:1518459080
Name:DIROBERTS, ADDIE ROBIN
Entity Type:Individual
Prefix:
First Name:ADDIE
Middle Name:ROBIN
Last Name:DIROBERTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6008 E CALLE DE POMPAS
Mailing Address - Street 2:
Mailing Address - City:CAVE CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85331-2509
Mailing Address - Country:US
Mailing Address - Phone:602-863-1862
Mailing Address - Fax:602-863-4388
Practice Address - Street 1:10240 W. 31ST AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85051
Practice Address - Country:US
Practice Address - Phone:602-863-1862
Practice Address - Fax:602-863-4388
Is Sole Proprietor?:No
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-16052101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZLAC-16052Medicaid