Provider Demographics
NPI:1932626991
Name:FABIYI, MOYOSORE MOSES
Entity Type:Individual
Prefix:
First Name:MOYOSORE
Middle Name:MOSES
Last Name:FABIYI
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 1:1951 NW 7TH AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-1112
Mailing Address - Country:US
Mailing Address - Phone:305-902-6347
Mailing Address - Fax:478-595-8858
Practice Address - Street 1:1951 NW 7TH AVE FL 33136
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1104
Practice Address - Country:US
Practice Address - Phone:305-902-6347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-29
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YM0800X
IL178.015275101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL376001106007Medicaid
IL376001106006Medicaid