Healthcare Provider Details

I. General information

NPI: 1922668508
Provider Name (Legal Business Name): SAMUEL ADEMOLA AKINWANDE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2019
Last Update Date: 09/22/2025
Certification Date: 09/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4324 W HARVARD AVE
FRESNO CA
93722-5183
US

IV. Provider business mailing address

372 ST MONTELENA CT
MADERA CA
93637-3805
US

V. Phone/Fax

Practice location:
  • Phone: 559-681-1470
  • Fax:
Mailing address:
  • Phone: 323-973-8930
  • Fax: 530-894-5791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number103366
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number103366
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number103366
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: