Provider Demographics
NPI:1932683323
Name:IBRAHAM, ROBERT MICHAEL (PHD, CASAC-M)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:MICHAEL
Last Name:IBRAHAM
Suffix:
Gender:M
Credentials:PHD, CASAC-M
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 TROUT ST
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11769-1529
Mailing Address - Country:US
Mailing Address - Phone:631-589-9500
Mailing Address - Fax:631-647-3130
Practice Address - Street 1:1448 5TH AVE
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-4147
Practice Address - Country:US
Practice Address - Phone:631-650-0117
Practice Address - Fax:631-309-6833
Is Sole Proprietor?:No
Enumeration Date:2018-09-20
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X, 103TC1900X, 103TP2701X, 103TA0400X
NY34794101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy