Provider Demographics
NPI:1588371066
Name:AJIBOSE, ADETUTU (PSYD)
Entity type:Individual
Prefix:
First Name:ADETUTU
Middle Name:
Last Name:AJIBOSE
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 1:872 WHITTENTON ST
Mailing Address - Street 2:
Mailing Address - City:TAUNTON
Mailing Address - State:MA
Mailing Address - Zip Code:02780-7522
Mailing Address - Country:US
Mailing Address - Phone:347-681-5422
Mailing Address - Fax:
Practice Address - Street 1:400 BALD HILL RD STE 530
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-6111
Practice Address - Country:US
Practice Address - Phone:401-349-3131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-03
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA000103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical