Provider Demographics
NPI:1710487293
Name:AJIBOLA, OMOLARA (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:OMOLARA
Middle Name:
Last Name:AJIBOLA
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 MELISA DR
Mailing Address - Street 2:
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20744-2582
Mailing Address - Country:US
Mailing Address - Phone:401-954-3493
Mailing Address - Fax:
Practice Address - Street 1:200 I ST SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20003-3317
Practice Address - Country:US
Practice Address - Phone:202-717-0062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-20
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC500811741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical