Healthcare Provider Details

I. General information

NPI: 1790209369
Provider Name (Legal Business Name): MRS. OPEYEMI EDGAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2017
Last Update Date: 04/19/2023
Certification Date: 04/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W WALNUT ST STE 375
PASADENA CA
91124-3201
US

IV. Provider business mailing address

840 N AVENUE 66
LOS ANGELES CA
90042-1508
US

V. Phone/Fax

Practice location:
  • Phone: 626-395-7100
  • Fax:
Mailing address:
  • Phone: 626-395-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW114705
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: