Provider Demographics
NPI:1164167177
Name:LAWAL, BUSARI TAJUDEEN
Entity Type:Individual
Prefix:
First Name:BUSARI
Middle Name:TAJUDEEN
Last Name:LAWAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7980 NEW RIGGS RD APT 108
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20783-4827
Mailing Address - Country:US
Mailing Address - Phone:240-603-4365
Mailing Address - Fax:
Practice Address - Street 1:7980 NEW RIGGS RD APT 108
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20783-4827
Practice Address - Country:US
Practice Address - Phone:240-603-4365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-03
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities