Healthcare Provider Details

I. General information

NPI: 1487366506
Provider Name (Legal Business Name): KANAYO AGBODIKE PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2022
Last Update Date: 02/25/2023
Certification Date: 02/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1918 BONITA AVE STE 200
BERKELEY CA
94704-1014
US

IV. Provider business mailing address

1918 BONITA AVE STE 200
BERKELEY CA
94704-1014
US

V. Phone/Fax

Practice location:
  • Phone: 510-471-3849
  • Fax:
Mailing address:
  • Phone: 510-471-3849
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: