Basic Information
| Provider Information | |||||||||
| NPI: | 1043519150 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OWENS | ||||||||
| FirstName: | ABDUL | ||||||||
| MiddleName: | RAHIM | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | I | ||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | OWENS | ||||||||
| OtherFirstName: | ABDUL | ||||||||
| OtherMiddleName: | RAHIM | ||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | I | ||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4368 LINCOLN AVE | ||||||||
| Address2: | 4368 LINCOLN | ||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946022529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5105313111 | ||||||||
| FaxNumber: | 5105308083 | ||||||||
| Practice Location | |||||||||
| Address1: | 4368 LINCOLN AVE | ||||||||
| Address2: | 4368 LINCOLN | ||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946022529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5105313111 | ||||||||
| FaxNumber: | 5105308083 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2011 | ||||||||
| LastUpdateDate: | 11/17/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | B6731917 | CA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101Y00000X | B6731917 | CA | N | Behavioral Health & Social Service Providers | Counselor | 172V00000X | Y | Other Service Providers | Community Health Worker |
ID Information
| ID | Type | State | Issuer | Description | 5BASEBALL | 01 | CA | MEDI-CAL | OTHER |