Provider Demographics
NPI:1871231043
Name:ABIMBOLA, AISHA
Entity Type:Individual
Prefix:
First Name:AISHA
Middle Name:
Last Name:ABIMBOLA
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 1:2740 W CHERRY LN
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-4173
Mailing Address - Country:US
Mailing Address - Phone:208-971-8704
Mailing Address - Fax:
Practice Address - Street 1:8590 W FAIRVIEW AVE STE A
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8320
Practice Address - Country:US
Practice Address - Phone:208-672-0260
Practice Address - Fax:208-321-7750
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-26
Last Update Date:2023-09-18
Deactivation Date:2022-06-30
Deactivation Code:
Reactivation Date:2023-09-18
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 251S00000X
ID440521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251S00000XAgenciesCommunity/Behavioral Health