Provider Demographics
NPI:1538654462
Name:ALLI, AJIBOLA G (LCADC, CCS, ICADC)
Entity Type:Individual
Prefix:
First Name:AJIBOLA
Middle Name:G
Last Name:ALLI
Suffix:
Gender:F
Credentials:LCADC, CCS, ICADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 HAUSMANN CT FL 1
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07040-3006
Mailing Address - Country:US
Mailing Address - Phone:973-380-9030
Mailing Address - Fax:
Practice Address - Street 1:15 HAUSMANN CT FL 1
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07040
Practice Address - Country:US
Practice Address - Phone:973-380-9030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-23
Last Update Date:2018-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00133900101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)