Provider Demographics
NPI:1730368424
Name:ROEBUCK, IRIS ANITA
Entity type:Individual
Prefix:
First Name:IRIS
Middle Name:ANITA
Last Name:ROEBUCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 S BEACON ST
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-3740
Mailing Address - Country:US
Mailing Address - Phone:310-547-3341
Mailing Address - Fax:
Practice Address - Street 1:921 S BEACON ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-3740
Practice Address - Country:US
Practice Address - Phone:310-547-3341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-30
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor