Provider Demographics
NPI:1639733405
Name:FALOMO, MOBOLAJI (AUD)
Entity Type:Individual
Prefix:
First Name:MOBOLAJI
Middle Name:
Last Name:FALOMO
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 DALEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21060-7683
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:351 DALEVIEW DR
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21060-7683
Practice Address - Country:US
Practice Address - Phone:608-338-8703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-27
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MD01455231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician