Provider Demographics
NPI:1265829790
Name:BOFOTOLA-AKEMBA, FAVOR (LCSW)
Entity Type:Individual
Prefix:
First Name:FAVOR
Middle Name:
Last Name:BOFOTOLA-AKEMBA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4807 HILLSIDE CT
Mailing Address - Street 2:
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-3893
Mailing Address - Country:US
Mailing Address - Phone:678-799-0647
Mailing Address - Fax:
Practice Address - Street 1:4807 HILLSIDE CT
Practice Address - Street 2:
Practice Address - City:POWDER SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30127-3893
Practice Address - Country:US
Practice Address - Phone:678-799-0647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-22
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0075451041C0700X
GAMSW006157104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker