Modupe R Adedoja, NP
Individual provider Active NPI Psychiatric/Mental Health Nurse Practitioner · Phoenix, AZ
NPI 1346567013 · NPPES record last updated Dec 14, 2023
Key facts
- NPI
- 1346567013
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Psychiatric/Mental Health Nurse Practitioner 363LP0808X
- License
- 288675 (AZ)
- Practice address
- 111 W Monroe St Ste 300
Phoenix, AZ 85003-1718 - Phone
- (205) 536-8400
- NPI assigned
- Apr 21, 2010
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 1
Medicare Care Compare profile
- Specialty
- Nurse Practitioner
- Education
- Other, 2014
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
Practice addresses (Care Compare)
12725 W Indian School Rd
Suite E101
Avondale, AZ 85392-9525
500 N Estrella Pkwy
Suite B2 PMB 439
Goodyear, AZ 85338-4136
7775 W Buckeye Rd
Suite 150
Phoenix, AZ 85043-4218
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in AZ
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20260223002056 | AZ | Practitioner - Nurse Practitioner | 7719468271 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Nurse Practitioner
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 628238 | NY | MD | Registered Nurse |
| 875172 | TX | MD | Registered Nurse |
| 288675 | AZ | MD | Family Nurse Practitioner |
| F346956 | NY | MD | Family Nurse Practitioner |
| AP138574 | TX | MD | Family Nurse Practitioner |
| 405441 | NY | MD | Psychiatric/Mental Health Nurse Practitioner |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Reformed Mind Health and Treatment LLC | Psychiatric/Mental Health | Current |
Accepting new patients |
Locations
12725 W Indian School Rd
Ste E101
Avondale, AZ 85392
Phone (480) 448-2929
500 N Estrella Pkwy
Ste B2
Goodyear, AZ 85338
Phone (602) 661-0200
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Registered Nurse | 163W00000X | 628238 | NY | |
| Registered Nurse | 163W00000X | 875172 | TX | |
| Family Nurse Practitioner | 363LF0000X | AP138574 | TX | |
| Family Nurse Practitioner | 363LF0000X | F346956 | NY | |
| Family Nurse Practitioner | 363LF0000X | 288675 | AZ | |
| Psychiatric/Mental Health Nurse Practitioner | 363LP0808X | 405441 | NY | |
| Psychiatric/Mental Health Nurse Practitioner | 363LP0808X | 288675 | AZ | Yes |
Addresses
Primary practice location
111 W Monroe St Ste 300
Phoenix, AZ 85003-1718
Mailing address
111 W Monroe St Ste 300
Phoenix, AZ 85003-1718
Phone (281) 725-7671
Other names
- Rafatu Yisa
Other providers in Phoenix, AZ
- Shannon Brittany Addington
- Thomas Edward Addison
- Addus Healthcare, Inc.
- Robert Addy
- Winifred A Adebiyi
- Adebola Adekanmbi
- Adel Shayegan DMD PC
- Adelante Healthcare, Inc
- Adelante Healthcare, Inc
- Adelante Healthcare, Inc
All providers in Phoenix, AZ · Psychiatric/Mental Health Nurse Practitioner in Arizona
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Dec 14, 2023. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.