Provider Demographics
NPI:1932809399
Name:ADEDEJI, BOLAJI FOLASADE
Entity Type:Individual
Prefix:
First Name:BOLAJI
Middle Name:FOLASADE
Last Name:ADEDEJI
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 1:5424 BRIXHAM CT
Mailing Address - Street 2:
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015-1921
Mailing Address - Country:US
Mailing Address - Phone:240-640-0511
Mailing Address - Fax:
Practice Address - Street 1:5424 BRIXHAM CT
Practice Address - Street 2:
Practice Address - City:BURKE
Practice Address - State:VA
Practice Address - Zip Code:22015-1921
Practice Address - Country:US
Practice Address - Phone:240-640-0511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA4116320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities