Healthcare Provider Details

I. General information

NPI: 1023773009
Provider Name (Legal Business Name): ADEWALE PSYCHOLOGICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2021
Last Update Date: 11/03/2021
Certification Date: 11/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 E COLORADO BLVD STE 500
PASADENA CA
91106-2371
US

IV. Provider business mailing address

1055 E COLORADO BLVD STE 500
PASADENA CA
91106-2371
US

V. Phone/Fax

Practice location:
  • Phone: 323-633-3892
  • Fax: 626-240-4699
Mailing address:
  • Phone: 323-633-3892
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JODY ADEWALE
Title or Position: CEO
Credential: PSY.D.
Phone: 323-633-3892