Provider Demographics
NPI:1962996371
Name:FAGBOLA, JOANA ABENA (LCSW)
Entity type:Individual
Prefix:
First Name:JOANA
Middle Name:ABENA
Last Name:FAGBOLA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JOANA
Other - Middle Name:ABENA
Other - Last Name:FITTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:20 SOUTH ST APT 1
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:CT
Mailing Address - Zip Code:06801-2500
Mailing Address - Country:US
Mailing Address - Phone:347-712-9719
Mailing Address - Fax:
Practice Address - Street 1:2527 GLEBE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-3109
Practice Address - Country:US
Practice Address - Phone:718-904-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-19
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY092894-1104100000X
NY093759-011041C0700X
CT0126921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1952-476-988OtherMONTEFIORE MEDICAL CENTER