Healthcare Provider Details

I. General information

NPI: 1053465880
Provider Name (Legal Business Name): BUKOLA E OLODE LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

971 JEROME ST
BROOKLYN NY
11207-9252
US

IV. Provider business mailing address

200 BETHEL LOOP APT 11C
BROOKLYN NY
11239-1714
US

V. Phone/Fax

Practice location:
  • Phone: 718-272-3300
  • Fax:
Mailing address:
  • Phone: 917-843-4295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number72070896
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: