Healthcare Provider Details

I. General information

NPI: 1871697243
Provider Name (Legal Business Name): ABIMBOLA AYODELE OGUNDEJI MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 12/30/2021
Certification Date: 12/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4647 ZION AVE
SAN DIEGO CA
92120-2507
US

IV. Provider business mailing address

774 VISTA SANTA INES
SAN DIEGO CA
92154-5677
US

V. Phone/Fax

Practice location:
  • Phone: 619-931-3761
  • Fax:
Mailing address:
  • Phone: 619-931-3761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT46193
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: