Provider Demographics
NPI:1871080358
Name:FAWOLE, ADEMOLA
Entity type:Individual
Prefix:DR
First Name:ADEMOLA
Middle Name:
Last Name:FAWOLE
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 1:2726 MAXWELL ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19136-1017
Mailing Address - Country:US
Mailing Address - Phone:215-939-0572
Mailing Address - Fax:
Practice Address - Street 1:513 W CHOCOLATE AVE STE 100
Practice Address - Street 2:
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033
Practice Address - Country:US
Practice Address - Phone:717-810-1974
Practice Address - Fax:717-704-8476
Is Sole Proprietor?:No
Enumeration Date:2018-04-19
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS018734103T00000X
WI3565-57103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist