Healthcare Provider Details

I. General information

NPI: 1811366784
Provider Name (Legal Business Name): IYAMIDE O HOUSE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2015
Last Update Date: 07/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1227 4TH ST NE
WASHINGTON DC
20002-3431
US

IV. Provider business mailing address

14558 LONDON LN
BOWIE MD
20715-2557
US

V. Phone/Fax

Practice location:
  • Phone: 202-543-8477
  • Fax:
Mailing address:
  • Phone: 845-282-6155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPRC14583
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPRC14583
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: