Healthcare Provider Details

I. General information

NPI: 1568393247
Provider Name (Legal Business Name): OLUFEMI OLUYOLE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2026
Last Update Date: 05/29/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1313 MILSTEAD AVE NE
CONYERS GA
30012-3829
US

IV. Provider business mailing address

796 BLACK MAPLE CT
LOGANVILLE GA
30052-6422
US

V. Phone/Fax

Practice location:
  • Phone: 678-677-4347
  • Fax:
Mailing address:
  • Phone: 678-677-4347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number1453310
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: