Provider Demographics
NPI:1801502976
Name:AKINBOLADE, ABIMBOLA
Entity type:Individual
Prefix:
First Name:ABIMBOLA
Middle Name:
Last Name:AKINBOLADE
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 1:1413 GABLES CT
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75075-7643
Mailing Address - Country:US
Mailing Address - Phone:972-655-7251
Mailing Address - Fax:855-568-2494
Practice Address - Street 1:155 DEAN ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11217-2213
Practice Address - Country:US
Practice Address - Phone:718-694-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-23
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP130591207R00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine