Healthcare Provider Details

I. General information

NPI: 1295384733
Provider Name (Legal Business Name): ADEDAYO M ADENEKAN BEHAVIOR SPECIALIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2019
Last Update Date: 09/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 COUNTRY CLUB EST
SALEM IL
62881-3631
US

IV. Provider business mailing address

109 COUNTRY CLUB EST
SALEM IL
62881-3631
US

V. Phone/Fax

Practice location:
  • Phone: 314-740-5639
  • Fax: 618-662-9519
Mailing address:
  • Phone: 314-740-5639
  • Fax: 618-662-9519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: