Healthcare Provider Details

I. General information

NPI: 1982770079
Provider Name (Legal Business Name): OLASUPO FAGBENLE LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 01/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18636 JORDAN AVE
SAINT ALBANS NY
11412-2308
US

IV. Provider business mailing address

18636 JORDAN AVE
SAINT ALBANS NY
11412-2308
US

V. Phone/Fax

Practice location:
  • Phone: 917-605-3771
  • Fax: 718-264-7797
Mailing address:
  • Phone: 917-605-3771
  • Fax: 718-264-7797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP48013
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8744914
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: