Provider Demographics
NPI:1811259773
Name:FASORO, ADEBUKOLA
Entity type:Individual
Prefix:
First Name:ADEBUKOLA
Middle Name:
Last Name:FASORO
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 1:11212 POMPEY DR
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-4875
Mailing Address - Country:US
Mailing Address - Phone:240-708-3148
Mailing Address - Fax:
Practice Address - Street 1:866 YUMA ST SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-3972
Practice Address - Country:US
Practice Address - Phone:240-708-3148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-15
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program