Provider Demographics
NPI:1871653154
Name:ROBERTS, RENEE (EDD)
Entity Type:Individual
Prefix:DR
First Name:RENEE
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:DR
Other - First Name:RENEE
Other - Middle Name:
Other - Last Name:REED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1405 W 16TH ST
Mailing Address - Street 2:STE C
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-4579
Mailing Address - Country:US
Mailing Address - Phone:928-783-4859
Mailing Address - Fax:928-782-3239
Practice Address - Street 1:1405 W 16TH ST
Practice Address - Street 2:STE C
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-4579
Practice Address - Country:US
Practice Address - Phone:928-783-4859
Practice Address - Fax:928-782-3239
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-09
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1057103T00000X
IN20040200A103T00000X
MI6301008688103T00000X
NVPY0428103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV36115Medicare PIN