Healthcare Provider Details

I. General information

NPI: 1265576813
Provider Name (Legal Business Name): MR. IGBINOSA NOEL AMADASUN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 08/11/2021
Certification Date: 08/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5417 MADISON AVE
SACRAMENTO CA
95841-3164
US

IV. Provider business mailing address

PO BOX 231305
SACRAMENTO CA
95823-0405
US

V. Phone/Fax

Practice location:
  • Phone: 916-583-2248
  • Fax:
Mailing address:
  • Phone: 916-549-8252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number115403
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number76536
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: