MEDICARE: MR. ADESINA P OGUNLANA LCSWR

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	054785	NY

General Provider Information

NPI Number	:	1457487647
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ADESINA P OGUNLANA LCSWR

Provider Business Mailing Address
First Line	:	27 LAGUNA LN
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10303-2482
Country	:	US
Telephone Number	:	718-818-9824
Fax Number	:

Provider Business Practice Location Address
First Line	:	2581 ATLANTIC AVE
Second Line	:	INSTITUTE FOR COMMUNITY LIVING
City	:	BROOKLYN
State	:	NY
Zip	:	11207-2412
Country	:	US
Telephone Number	:	718-495-6700
Fax Number	:

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

Provider Enumeration Date	:	02/24/2007
Last Update Date	:	07/08/2007

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