Provider Demographics
NPI:1720453715
Name:LAWAL, OLUSHOLA (MSW)
Entity Type:Individual
Prefix:
First Name:OLUSHOLA
Middle Name:
Last Name:LAWAL
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1416 NE 5TH CT APT 4
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-1272
Mailing Address - Country:US
Mailing Address - Phone:850-345-8732
Mailing Address - Fax:
Practice Address - Street 1:1416 NE 5TH CT APT 4
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33301-1272
Practice Address - Country:US
Practice Address - Phone:850-345-8732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-02
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
FL14449171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1720453715Medicaid