Provider Demographics
NPI:1457907826
Name:AGBOOLA, OLAWALE
Entity Type:Individual
Prefix:
First Name:OLAWALE
Middle Name:
Last Name:AGBOOLA
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 1:616 MISTFLOWER DR NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30102-6934
Mailing Address - Country:US
Mailing Address - Phone:317-319-7616
Mailing Address - Fax:
Practice Address - Street 1:616 MISTFLOWER DR NW
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30102-6934
Practice Address - Country:US
Practice Address - Phone:317-319-7616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-12
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-23-66558103K00000X
GA1-23-665558103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst