Provider Demographics
NPI:1932390085
Name:ERENBERG, ILYA (MA)
Entity Type:Individual
Prefix:MR
First Name:ILYA
Middle Name:
Last Name:ERENBERG
Suffix:
Gender:M
Credentials:MA
Other - Prefix:MR
Other - First Name:I.
Other - Middle Name:NIKOLAI
Other - Last Name:ERENBERG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:2325 MCKINLEY AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94703-1734
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:668 QUINAN ST
Practice Address - Street 2:
Practice Address - City:PINOLE
Practice Address - State:CA
Practice Address - Zip Code:94564-1621
Practice Address - Country:US
Practice Address - Phone:510-741-7286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-05
Last Update Date:2007-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No103T00000XBehavioral Health & Social Service ProvidersPsychologist