Provider Demographics
NPI:1093991085
Name:AGBOOLA, JOHN G
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:G
Last Name:AGBOOLA
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 1:76 CARRIAGE DR
Mailing Address - Street 2:
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02740-1872
Mailing Address - Country:US
Mailing Address - Phone:508-993-6255
Mailing Address - Fax:
Practice Address - Street 1:100 N FRONT ST
Practice Address - Street 2:
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02740-7350
Practice Address - Country:US
Practice Address - Phone:508-994-0885
Practice Address - Fax:508-994-0409
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-21
Last Update Date:2008-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)