Provider Demographics
NPI:1265204259
Name:ADEAGBO, OLUSEYI
Entity type:Individual
Prefix:
First Name:OLUSEYI
Middle Name:
Last Name:ADEAGBO
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 1:1347 POMPAY DR
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33896-8631
Mailing Address - Country:US
Mailing Address - Phone:954-999-1222
Mailing Address - Fax:
Practice Address - Street 1:1803 PARK CENTER DR STE 212
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-6216
Practice Address - Country:US
Practice Address - Phone:407-907-2077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-24
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-306267106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician