Provider Demographics
NPI:1922668508
Name:AKINWANDE, SAMUEL ADEMOLA
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:ADEMOLA
Last Name:AKINWANDE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:372 ST MONTELENA CT
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93637-3805
Mailing Address - Country:US
Mailing Address - Phone:323-973-8930
Mailing Address - Fax:530-894-5791
Practice Address - Street 1:4324 W HARVARD AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93722-5183
Practice Address - Country:US
Practice Address - Phone:559-681-1470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-17
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103366101YM0800X
101YM0800X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health