Provider Demographics
NPI:1467964866
Name:AYODABO, KAYODE ILESANMI (ADDICTION COUNSELOR)
Entity Type:Individual
Prefix:
First Name:KAYODE
Middle Name:ILESANMI
Last Name:AYODABO
Suffix:
Gender:M
Credentials:ADDICTION COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7144 TEXAS BLVD
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27360-5382
Mailing Address - Country:US
Mailing Address - Phone:336-313-6733
Mailing Address - Fax:
Practice Address - Street 1:1203 BRANDT ST STE F
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-3505
Practice Address - Country:US
Practice Address - Phone:336-905-7688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-25
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)