Provider Demographics
NPI:1487725792
Name:AVENSON, ROBERT (PHD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:AVENSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 764
Mailing Address - Street 2:
Mailing Address - City:ROSS
Mailing Address - State:CA
Mailing Address - Zip Code:94957-0764
Mailing Address - Country:US
Mailing Address - Phone:510-527-9767
Mailing Address - Fax:
Practice Address - Street 1:1035 SAN PABLO AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:ALBANY
Practice Address - State:CA
Practice Address - Zip Code:94706-2275
Practice Address - Country:US
Practice Address - Phone:510-527-9767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPL 10033103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL100330Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER