Provider Demographics
NPI:1043845910
Name:FANILOLA, BOLANLE (LMSW)
Entity Type:Individual
Prefix:
First Name:BOLANLE
Middle Name:
Last Name:FANILOLA
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10100 PALACE WAY APT B
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23238-5646
Mailing Address - Country:US
Mailing Address - Phone:443-416-9572
Mailing Address - Fax:
Practice Address - Street 1:681 HIOAKS RD STE J
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23225-4043
Practice Address - Country:US
Practice Address - Phone:804-533-1330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD22958104100000X
VA0903002957104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker