Provider Demographics
NPI:1407580749
Name:ADEGBOLA, VICTOR (LSW)
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:
Last Name:ADEGBOLA
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3974 BROWN PARK DR STE A
Mailing Address - Street 2:
Mailing Address - City:HILLIARD
Mailing Address - State:OH
Mailing Address - Zip Code:43026-1168
Mailing Address - Country:US
Mailing Address - Phone:614-353-4157
Mailing Address - Fax:
Practice Address - Street 1:3974 BROWN PARK DR STE A
Practice Address - Street 2:
Practice Address - City:HILLIARD
Practice Address - State:OH
Practice Address - Zip Code:43026-1168
Practice Address - Country:US
Practice Address - Phone:614-353-4157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-12
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.00162221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHS.0016222OtherSOCIAL WORK LICENSE NUMBER