Provider Demographics
NPI:1730471731
Name:ID-DEEN, MAKEBA M (MA)
Entity Type:Individual
Prefix:
First Name:MAKEBA
Middle Name:M
Last Name:ID-DEEN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:MAKEBA
Other - Middle Name:
Other - Last Name:ID-DEEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:401 ROLAND WAY STE 150
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94621-2027
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 ROLAND WAY STE 150
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94621-2027
Practice Address - Country:US
Practice Address - Phone:510-839-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-09
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 171M00000X
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health