Basic Information
| Provider Information | |||||||||
| NPI: | 1093444101 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AMOLE | ||||||||
| FirstName: | ADELOWO | ||||||||
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| Credential: | MA, LLC | ||||||||
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| OtherLastName: | AMOLE | ||||||||
| OtherFirstName: | MOSES | ||||||||
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| OtherCredential: | MA, LLC | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6549 TOWN CENTER DR STE A | ||||||||
| Address2: | |||||||||
| City: | CLARKSTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483464824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003953223 | ||||||||
| FaxNumber: | 8333296632 | ||||||||
| Practice Location | |||||||||
| Address1: | 2300 JOLLY OAK RD | ||||||||
| Address2: | |||||||||
| City: | OKEMOS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488643546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003953223 | ||||||||
| FaxNumber: | 8333296632 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2022 | ||||||||
| LastUpdateDate: | 10/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 247200000X | N | Technologists, Technicians & Other Technical Service Providers | Technician, Other | 101YP2500X | 6451022591 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.