Provider Demographics
NPI:1831648948
Name:LASISI, AMUDALAT FOLA (LMHC)
Entity Type:Individual
Prefix:
First Name:AMUDALAT
Middle Name:FOLA
Last Name:LASISI
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14450 177TH ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-4918
Mailing Address - Country:US
Mailing Address - Phone:347-869-7660
Mailing Address - Fax:
Practice Address - Street 1:1045 JAMES ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-2730
Practice Address - Country:US
Practice Address - Phone:315-472-4471
Practice Address - Fax:315-472-1759
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-30
Last Update Date:2018-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
NY008259101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)