Provider Demographics
NPI:1306214085
Name:AMOSU, GBENADE
Entity Type:Individual
Prefix:
First Name:GBENADE
Middle Name:
Last Name:AMOSU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7029 RUTLAND ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19149-1717
Mailing Address - Country:US
Mailing Address - Phone:215-941-9885
Mailing Address - Fax:215-821-2029
Practice Address - Street 1:7029 RUTLAND ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19149-1717
Practice Address - Country:US
Practice Address - Phone:215-941-9885
Practice Address - Fax:215-821-2029
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-11
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH002827103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst