MEDICARE: VICTOR ADEGBOLA LSW

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	S.0016222	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	S.0016222	OTHER	OH	SOCIAL WORK LICENSE NUMBER

General Provider Information

NPI Number	:	1407580749
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VICTOR ADEGBOLA LSW

Provider Business Mailing Address
First Line	:	3974 BROWN PARK DR STE A
Second Line	:
City	:	HILLIARD
State	:	OH
Zip	:	43026-1168
Country	:	US
Telephone Number	:	614-353-4157
Fax Number	:

Provider Business Practice Location Address
First Line	:	3974 BROWN PARK DR STE A
Second Line	:
City	:	HILLIARD
State	:	OH
Zip	:	43026-1168
Country	:	US
Telephone Number	:	614-353-4157
Fax Number	:

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

Provider Enumeration Date	:	07/12/2022
Last Update Date	:	07/12/2022

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