Healthcare Provider Details

I. General information

NPI: 1063754182
Provider Name (Legal Business Name): MR. MODEBOLA FADARE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2013
Last Update Date: 05/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9210 S WESTERN AVE STE A-21
OKLAHOMA CITY OK
73139-4982
US

IV. Provider business mailing address

9210 S WESTERN AVE STE A-21
OKLAHOMA CITY OK
73139-4982
US

V. Phone/Fax

Practice location:
  • Phone: 405-246-9259
  • Fax: 405-606-7893
Mailing address:
  • Phone: 405-246-9259
  • Fax: 405-606-7893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6107
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: