Provider Demographics
NPI:1770219875
Name:IGBINOSUN, IMUENTIYAN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:IMUENTIYAN
Middle Name:
Last Name:IGBINOSUN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 SE 4TH AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-1900
Mailing Address - Country:US
Mailing Address - Phone:954-766-4955
Mailing Address - Fax:
Practice Address - Street 1:1421 SE 4TH AVE FL 2
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-1900
Practice Address - Country:US
Practice Address - Phone:954-766-4955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-29
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health