Basic Information
| Provider Information | |||||||||
| NPI: | 1659951689 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOLAWOLE | ||||||||
| FirstName: | MOTUN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 MANHATTAN AVE | ||||||||
| Address2: | |||||||||
| City: | WHITE PLAINS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 106071329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9147616134 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 30 MANHATTAN AVE | ||||||||
| Address2: | |||||||||
| City: | WHITE PLAINS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 106071329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9147616134 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2021 | ||||||||
| LastUpdateDate: | 04/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | 40545 | NY | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.