Provider Demographics
NPI:1174035331
Name:POPOOLA, FATAI ADESHINA (LGSW,LADC)
Entity Type:Individual
Prefix:
First Name:FATAI
Middle Name:ADESHINA
Last Name:POPOOLA
Suffix:
Gender:M
Credentials:LGSW,LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8628 PLATINUM CV
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129-7559
Mailing Address - Country:US
Mailing Address - Phone:651-214-0975
Mailing Address - Fax:
Practice Address - Street 1:625 SNELLING AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-2878
Practice Address - Country:US
Practice Address - Phone:651-214-0975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-27
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303521101YA0400X
103TA0400X
MN249381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical