Healthcare Provider Details

I. General information

NPI: 1174035331
Provider Name (Legal Business Name): FATAI ADESHINA POPOOLA LICSW,LADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2017
Last Update Date: 02/06/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 PORTLAND AVE # MC963
MINNEAPOLIS MN
55415-1533
US

IV. Provider business mailing address

525 PORTLAND AVE # MC963
MINNEAPOLIS MN
55415-1533
US

V. Phone/Fax

Practice location:
  • Phone: 612-396-2280
  • Fax:
Mailing address:
  • Phone: 612-396-2280
  • Fax: 612-466-9432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number303521
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number24938
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: