Provider Demographics
NPI:1639957277
Name:ROBERSON, IDRIS
Entity Type:Individual
Prefix:
First Name:IDRIS
Middle Name:
Last Name:ROBERSON
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 1:4494 W PEORIA AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302-2024
Mailing Address - Country:US
Mailing Address - Phone:602-687-2043
Mailing Address - Fax:623-440-4285
Practice Address - Street 1:4494 W PEORIA AVE STE 101
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-2024
Practice Address - Country:US
Practice Address - Phone:602-687-2043
Practice Address - Fax:623-440-4285
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-15
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
320600000X
AZ221509-14979320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities