Provider Demographics
NPI:1679880678
Name:OSHAUGHNESSY, ADEPEJU IBIRONKE FABORO (LMHC, LPC)
Entity Type:Individual
Prefix:MRS
First Name:ADEPEJU
Middle Name:IBIRONKE FABORO
Last Name:OSHAUGHNESSY
Suffix:
Gender:F
Credentials:LMHC, LPC
Other - Prefix:
Other - First Name:ADEPEJU
Other - Middle Name:IBIRONKE
Other - Last Name:FABORO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:44 BUCKTAIL AVE
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081-6181
Mailing Address - Country:US
Mailing Address - Phone:405-473-4945
Mailing Address - Fax:
Practice Address - Street 1:44 BUCKTAIL AVE
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32081-6181
Practice Address - Country:US
Practice Address - Phone:405-473-4945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-12
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6063101YP2500X
TX81315101YP2500X
FLMH16093101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200331240BMedicaid