Provider Demographics
NPI:1578033544
Name:ADEGBESAN, ANDRIA
Entity Type:Individual
Prefix:
First Name:ANDRIA
Middle Name:
Last Name:ADEGBESAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 MELROSE AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-2050
Mailing Address - Country:US
Mailing Address - Phone:410-222-6409
Mailing Address - Fax:
Practice Address - Street 1:415 MELROSE AVE
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-2050
Practice Address - Country:US
Practice Address - Phone:410-222-6409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-03
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD7408Medicaid