Provider Demographics
NPI:1558824003
Name:PSYCH-MD, LLC
Entity Type:Organization
Organization Name:PSYCH-MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:OLULEYE
Authorized Official - Middle Name:
Authorized Official - Last Name:ADIGUN
Authorized Official - Suffix:
Authorized Official - Credentials:MCAP
Authorized Official - Phone:786-785-0585
Mailing Address - Street 1:11924 NW 12TH ST
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33026-3856
Mailing Address - Country:US
Mailing Address - Phone:786-785-0585
Mailing Address - Fax:
Practice Address - Street 1:11924 NW 12TH ST
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-3856
Practice Address - Country:US
Practice Address - Phone:786-785-0585
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1255843652OtherNPI
FL1255843652Medicaid