Provider Demographics
NPI:1255197430
Name:FAGBENRO, ABIOLA O
Entity type:Individual
Prefix:
First Name:ABIOLA
Middle Name:O
Last Name:FAGBENRO
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 1:96 ETHEL ST
Mailing Address - Street 2:
Mailing Address - City:METUCHEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08840-2943
Mailing Address - Country:US
Mailing Address - Phone:201-515-0800
Mailing Address - Fax:
Practice Address - Street 1:96 ETHEL ST
Practice Address - Street 2:
Practice Address - City:METUCHEN
Practice Address - State:NJ
Practice Address - Zip Code:08840-2943
Practice Address - Country:US
Practice Address - Phone:201-515-0800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician