Provider Demographics
NPI:1144384058
Name:BANJOKO, OSUN TOKI
Entity Type:Individual
Prefix:
First Name:OSUN
Middle Name:TOKI
Last Name:BANJOKO
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:DANNY
Other - Middle Name:MITCHELL
Other - Last Name:BAGLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3219 PIERCE ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94804-5910
Mailing Address - Country:US
Mailing Address - Phone:510-559-5550
Mailing Address - Fax:
Practice Address - Street 1:3219 PIERCE ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94804-5910
Practice Address - Country:US
Practice Address - Phone:510-559-5550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSB#31955101Y00000X, 101YM0800X
103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent