MEDICARE: FAVOR BOFOTOLA-AKEMBA LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	CSW007545	GA
2	104100000X	Social Worker	MSW006157	GA

General Provider Information

NPI Number	:	1265829790
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FAVOR BOFOTOLA-AKEMBA LCSW

Provider Business Mailing Address
First Line	:	4807 HILLSIDE CT
Second Line	:
City	:	POWDER SPRINGS
State	:	GA
Zip	:	30127-3893
Country	:	US
Telephone Number	:	678-799-0647
Fax Number	:

Provider Business Practice Location Address
First Line	:	4807 HILLSIDE CT
Second Line	:
City	:	POWDER SPRINGS
State	:	GA
Zip	:	30127-3893
Country	:	US
Telephone Number	:	678-799-0647
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/22/2015
Last Update Date	:	04/08/2021

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