Provider Demographics
NPI:1821507856
Name:BAMGBOSE, OLUBUNKUNOLA
Entity Type:Individual
Prefix:
First Name:OLUBUNKUNOLA
Middle Name:
Last Name:BAMGBOSE
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 1:1690 LONGFELLOW AVE APT 1L
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10460-5424
Mailing Address - Country:US
Mailing Address - Phone:917-564-1650
Mailing Address - Fax:
Practice Address - Street 1:2700 WESCHESTER AVENUE
Practice Address - Street 2:300
Practice Address - City:PURCHASE
Practice Address - State:NY
Practice Address - Zip Code:10577
Practice Address - Country:US
Practice Address - Phone:914-328-2868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-21
Last Update Date:2017-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool