MEDICARE: DR. ADAOBI C IHEDURU PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY004016	GA

General Provider Information

NPI Number	:	1578810859
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ADAOBI C IHEDURU PSY.D.

Provider Business Mailing Address
First Line	:	4684 STONEHENGE DR
Second Line	:
City	:	PEACHTREE CORNERS
State	:	GA
Zip	:	30096-2989
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4020 E PONCE DE LEON AVE
Second Line	:
City	:	CLARKSTON
State	:	GA
Zip	:	30021-1815
Country	:	US
Telephone Number	:	470-545-2776
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/06/2012
Last Update Date	:	12/30/2025

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