Basic Information
| Provider Information | |||||||||
| NPI: | 1578003703 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLADALE | ||||||||
| FirstName: | DAMILOLA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1125 VAN ARSDALE DR | ||||||||
| Address2: | |||||||||
| City: | BRANCHBURG | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088534145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5042617266 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1125 VAN ARSDALE DR | ||||||||
| Address2: | |||||||||
| City: | BRANCHBURG | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088534145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5042617266 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2017 | ||||||||
| LastUpdateDate: | 06/14/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 253Z00000X | N | Agencies | In Home Supportive Care | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.