Healthcare Provider Details

I. General information

NPI: 1669405270
Provider Name (Legal Business Name): ISAAC ABIOYE OLASUPO MSC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2116 N CHARLES ST SUIT 300
BALTIMORE MD
21218-5758
US

IV. Provider business mailing address

6510 JODIE ST
NEW CARROLLTON MD
20784-3636
US

V. Phone/Fax

Practice location:
  • Phone: 410-244-0331
  • Fax: 410-244-7364
Mailing address:
  • Phone: 301-345-4787
  • Fax: 301-345-5310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number408449700, 409426300
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: