Provider Demographics
NPI:1720453715
Name:LAWAL, OLUSHOLA (MSW)
Entity type:Individual
Prefix:
First Name:OLUSHOLA
Middle Name:
Last Name:LAWAL
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2816 NW 80TH AVE
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33322-2405
Mailing Address - Country:US
Mailing Address - Phone:850-345-8732
Mailing Address - Fax:
Practice Address - Street 1:2400 W 64TH ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55423-1001
Practice Address - Country:US
Practice Address - Phone:612-767-7222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-02
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN334141041C0700X
FL14449171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1720453715Medicaid