Healthcare Provider Details

I. General information

NPI: 1386321727
Provider Name (Legal Business Name): YETUNDE ILAWOLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2023
Last Update Date: 03/05/2026
Certification Date: 03/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4545 42ND ST NW STE 105
WASHINGTON DC
20016-4623
US

IV. Provider business mailing address

20134 PRAIRIE DUNN TER
ASHBURN VA
20147
US

V. Phone/Fax

Practice location:
  • Phone: 202-558-2085
  • Fax:
Mailing address:
  • Phone: 228-558-2085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: