Provider Demographics
NPI:1952913360
Name:KOLAPO, MUTIU
Entity Type:Individual
Prefix:
First Name:MUTIU
Middle Name:
Last Name:KOLAPO
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 1:6837 DANRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75089-2004
Mailing Address - Country:US
Mailing Address - Phone:832-290-8275
Mailing Address - Fax:
Practice Address - Street 1:6837 DANRIDGE RD
Practice Address - Street 2:
Practice Address - City:ROWLETT
Practice Address - State:TX
Practice Address - Zip Code:75089-2004
Practice Address - Country:US
Practice Address - Phone:832-290-8275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-18
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX171M00000X, 101YM0800X
385H00000X, 3104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No385H00000XRespite Care FacilityRespite Care