Healthcare Provider Details

I. General information

NPI: 1295343929
Provider Name (Legal Business Name): ADEKUNLE J GBADAMOSI LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2020
Last Update Date: 03/18/2022
Certification Date: 03/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 BLACKHORSE HILL RD
COATESVILLE PA
19320-2040
US

IV. Provider business mailing address

2 CORKWOOD LN
NEW CASTLE DE
19720-7670
US

V. Phone/Fax

Practice location:
  • Phone: 610-384-7711
  • Fax:
Mailing address:
  • Phone: 302-384-3194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPC-0000630
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: