Provider Demographics
NPI:1174287502
Name:OLAIFA, DAMILOLA I
Entity type:Individual
Prefix:
First Name:DAMILOLA
Middle Name:I
Last Name:OLAIFA
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 1:480 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91007-6873
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 W F ST STE 101
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-3201
Practice Address - Country:US
Practice Address - Phone:818-206-0360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-22
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACI41730224101YA0400X
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician