Provider Demographics
NPI:1093444101
Name:AMOLE, ADELOWO (MA, MHC-LP)
Entity Type:Individual
Prefix:
First Name:ADELOWO
Middle Name:
Last Name:AMOLE
Suffix:
Gender:M
Credentials:MA, MHC-LP
Other - Prefix:
Other - First Name:MOSES
Other - Middle Name:
Other - Last Name:AMOLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA, MHC-LP
Mailing Address - Street 1:3600 ROUTE 112
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-4116
Mailing Address - Country:US
Mailing Address - Phone:631-920-8546
Mailing Address - Fax:929-244-4997
Practice Address - Street 1:3600 ROUTE 112
Practice Address - Street 2:
Practice Address - City:CORAM
Practice Address - State:NY
Practice Address - Zip Code:11727-4116
Practice Address - Country:US
Practice Address - Phone:631-920-8546
Practice Address - Fax:929-244-4997
Is Sole Proprietor?:No
Enumeration Date:2022-06-06
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP119805101YM0800X
MI6451022591101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health