Provider Demographics
NPI:1255197455
Name:FADAHUNSI, OLUMUYIWA ISHOLA
Entity type:Individual
Prefix:
First Name:OLUMUYIWA
Middle Name:ISHOLA
Last Name:FADAHUNSI
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 1:1153 BERGEN ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07112-2201
Mailing Address - Country:US
Mailing Address - Phone:862-703-1375
Mailing Address - Fax:
Practice Address - Street 1:1153 BERGEN ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07112-2201
Practice Address - Country:US
Practice Address - Phone:862-703-1375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor