Provider Demographics
NPI:1477321891
Name:ADESANYA, BOLAJI JOHNSON
Entity Type:Individual
Prefix:
First Name:BOLAJI
Middle Name:JOHNSON
Last Name:ADESANYA
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 1:714 MAIN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-6010
Mailing Address - Country:US
Mailing Address - Phone:541-647-1945
Mailing Address - Fax:
Practice Address - Street 1:714 MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-6010
Practice Address - Country:US
Practice Address - Phone:541-647-1945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-14
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR22-QMHP-R-1638101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health