Provider Demographics
NPI:1659951689
Name:KOLAWOLE, MOTUN
Entity Type:Individual
Prefix:
First Name:MOTUN
Middle Name:
Last Name:KOLAWOLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 MANHATTAN AVE
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10607-1329
Mailing Address - Country:US
Mailing Address - Phone:914-761-6134
Mailing Address - Fax:
Practice Address - Street 1:30 MANHATTAN AVE
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10607-1329
Practice Address - Country:US
Practice Address - Phone:914-761-6134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-13
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY40545171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator