Provider Demographics
NPI:1497111835
Name:BADAMOSI, ABIODUN
Entity Type:Individual
Prefix:
First Name:ABIODUN
Middle Name:
Last Name:BADAMOSI
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 1:2697 INTERNATIONAL PKWY 1
Mailing Address - Street 2:SUITE 207
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-7803
Mailing Address - Country:US
Mailing Address - Phone:757-752-3839
Mailing Address - Fax:
Practice Address - Street 1:2697 INTERNATIONAL PKWY 1
Practice Address - Street 2:SUITE 207
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-7803
Practice Address - Country:US
Practice Address - Phone:757-752-3839
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-14
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2413101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA474661869Medicaid