Provider Demographics
NPI:1295806156
Name:FAMUYIDE, DEBORAH BOLANLE (LCSW, CASAC)
Entity type:Individual
Prefix:MRS
First Name:DEBORAH
Middle Name:BOLANLE
Last Name:FAMUYIDE
Suffix:
Gender:F
Credentials:LCSW, CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2750 ATLANTIC AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11207-2811
Mailing Address - Country:US
Mailing Address - Phone:718-647-6699
Mailing Address - Fax:718-647-6777
Practice Address - Street 1:2750 ATLANTIC AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11207-2811
Practice Address - Country:US
Practice Address - Phone:718-647-6699
Practice Address - Fax:718-647-6777
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY11507101YA0400X
NYR0537681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYD1983848Medicaid
NYD1983848Medicaid