Provider Demographics
NPI:1215616768
Name:GIDEON, ROBERT EUGENE
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:EUGENE
Last Name:GIDEON
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 1:1008 SEACOAST DR
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91932-2504
Mailing Address - Country:US
Mailing Address - Phone:619-763-9051
Mailing Address - Fax:
Practice Address - Street 1:1501 IMPERIAL AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-7638
Practice Address - Country:US
Practice Address - Phone:619-865-1454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1455910122101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)