Healthcare Provider Details

I. General information

NPI: 1093089435
Provider Name (Legal Business Name): ADEKUNLE IGE ASW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2012
Last Update Date: 06/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22245 MAIN ST STE 200
HAYWARD CA
94541-4028
US

IV. Provider business mailing address

89 TOPEKA AVE
SAN JOSE CA
95128-1852
US

V. Phone/Fax

Practice location:
  • Phone: 510-727-9401
  • Fax:
Mailing address:
  • Phone: 267-294-7668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number33143
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: