Healthcare Provider Details

I. General information

NPI: 1720691777
Provider Name (Legal Business Name): IFEDOLA 0 OLOWE HS-BCP 2303
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2020
Last Update Date: 08/28/2020
Certification Date: 08/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

442 BEACH 46TH ST
FAR ROCKAWAY NY
11691-1114
US

IV. Provider business mailing address

442 BEACH 46TH ST
FAR ROCKAWAY NY
11691-1114
US

V. Phone/Fax

Practice location:
  • Phone: 917-971-1074
  • Fax:
Mailing address:
  • Phone: 917-971-1074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number2303
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: