Healthcare Provider Details

I. General information

NPI: 1447309216
Provider Name (Legal Business Name): EILEEN DENISE ROBERTS PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: EILEEN ROBERTS PHD

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 11/01/2024
Certification Date: 11/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1123 S CLOVERDALE BLVD # 112
CLOVERDALE CA
95425-4402
US

IV. Provider business mailing address

1123 S CLOVERDALE BLVD # 112
CLOVERDALE CA
95425-4402
US

V. Phone/Fax

Practice location:
  • Phone: 707-867-6635
  • Fax:
Mailing address:
  • Phone: 707-867-6635
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY21286
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY21296
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: