Provider Demographics
NPI:1558682062
Name:OMISORE, ABIMBOLA (LCSW)
Entity Type:Individual
Prefix:
First Name:ABIMBOLA
Middle Name:
Last Name:OMISORE
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:PO BOX 265
Mailing Address - Street 2:
Mailing Address - City:METUCHEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08840-0265
Mailing Address - Country:US
Mailing Address - Phone:973-714-6586
Mailing Address - Fax:
Practice Address - Street 1:328 DENISON ST
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:NJ
Practice Address - Zip Code:08904-2732
Practice Address - Country:US
Practice Address - Phone:973-714-6586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-18
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC054056001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical