Provider Demographics
NPI:1346717915
Name:MUSA-AGBONENI, AISABOMEN (LMSW)
Entity Type:Individual
Prefix:
First Name:AISABOMEN
Middle Name:
Last Name:MUSA-AGBONENI
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 VANDERBILT AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-3570
Mailing Address - Country:US
Mailing Address - Phone:347-788-8216
Mailing Address - Fax:
Practice Address - Street 1:260 BROADWAY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211-8433
Practice Address - Country:US
Practice Address - Phone:540-849-5152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-31
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY100867-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker