Edwin Japheth Agbonavbare, CNP
Individual provider Active NPI Psychiatric/Mental Health Nurse Practitioner · Peabody, MA
NPI 1386007631 · NPPES record last updated Dec 10, 2024
Key facts
- NPI
- 1386007631
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Psychiatric/Mental Health Nurse Practitioner 363LP0808X
- License
- RN2277840 (MA)
- Practice address
- 100 Corporate PL Ste 303
Peabody, MA 01960-3809 - Phone
- (781) 640-1791
- NPI assigned
- Apr 4, 2016
- Sex
- Male
- Sole proprietor
- Yes
Organizations & group practices 8
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in MA, NY
- 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 |
|---|---|---|---|---|
| I20201228000824 | MA | Practitioner - Nurse Practitioner | 5496168080 | Reassigns benefits to 6 organizations |
| I20250122002049 | NY | Practitioner - Nurse Practitioner | 5496168080 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Certified Nurse Practitioner, Nurse Practitioner
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| RN2277840 | MA | MD | Psychiatric/Mental Health Nurse Practitioner |
| 406565 | NY | MD | Psychiatric/Mental Health Nurse Practitioner |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Steward Medical Group, Inc | Single Specialty | Current |
Accepting new patients |
| Vantage Healthcare LLC | Single Specialty | Current |
Accepting new patients |
| Uhs of Westwood Pembroke Inc | Single Specialty | Current |
Accepting new patients |
| Supportive Behavioral Care of Ma LLC | Single Specialty | Current |
Accepting new patients |
| Steward Medical Group, Inc | Single Specialty | Current |
Accepting new patients |
| Thrive Counseling LLC | Single Specialty | Current |
Accepting new patients |
| Valera Medical, P.C. | Single Specialty | Current |
Accepting new patients |
| Rejuvenate Psychiatric Mental Health Services, LLC | Current |
Accepting new patients |
Locations
200 Groton Rd
Ayer, MA 01432
Phone (978) 784-9000
44 School St
Rm 325
Boston, MA 02108
Phone (508) 831-8558
11 Nevins St
Ste 201
Brighton, MA 02135
Phone (617) 789-2442
872 Massachusetts Ave
Ste 2-2
Cambridge, MA 02139
Phone 6173804651 ext. 1992
45 Dan Rd
Canton, MA 02021
Phone (781) 318-3609
225 Cedar Hill St
Ste 200
Marlborough, MA 01752
Phone (617) 863-9090
100 Corporate Pl
Ste 303
Peabody, MA 01960
Phone (781) 640-1791
199 Oak St
Pembroke, MA 02359
Phone (781) 829-7000
27 Randolph Rd
Howell, NJ 07731
Phone (972) 677-7951
134 N 4th St
Brooklyn, NY 11249
139 Centre St
Ste 824
New York, NY 10013
Phone (646) 450-7751
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Psychiatric/Mental Health Nurse Practitioner | 363LP0808X | 406565 | NY | |
| Psychiatric/Mental Health Nurse Practitioner |
363LP0808X | RN2277840 | MA | Yes |
Addresses
Primary practice location
100 Corporate PL Ste 303
Peabody, MA 01960-3809
Mailing address
100 Corporate PL Ste 303
Peabody, MA 01960-3809
Phone (781) 640-1791
Other providers in Peabody, MA
- William Paul Adams
- Odunayo S Adelusi
- Whitney Adrien Dadaille
- Advanced Endodontic Associates, PC
- Advocates, Inc
- Jessica I Agenor
- Nidhi Aggarwal
- Tanja Agolli
- Jessica Anne Ahearn
- Shemma Ahmed
All providers in Peabody, MA · Psychiatric/Mental Health Nurse Practitioner in Massachusetts
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Dec 10, 2024. 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).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.