MEDICARE: JODY J ADEWALE 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	225C00000X	Rehabilitation Counselor	2012306	CA
2	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1740591460
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JODY J ADEWALE PSY.D.

Provider Business Mailing Address
First Line	:	4519 ROSEMEAD BLVD
Second Line	:	FL 2
City	:	ROSEMEAD
State	:	CA
Zip	:	91770-1476
Country	:	US
Telephone Number	:	323-633-3892
Fax Number	:

Provider Business Practice Location Address
First Line	:	1055 E COLORADO BLVD FL 5FLOOR
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91106-2327
Country	:	US
Telephone Number	:	323-633-3892
Fax Number	:	626-240-4699

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

Provider Enumeration Date	:	06/28/2010
Last Update Date	:	05/21/2020

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