Healthcare Provider Details

I. General information

NPI: 1871900845
Provider Name (Legal Business Name): OMORUYI EPHRAIM OKUNDAYE MSW, LCSW-C, LCADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2014
Last Update Date: 07/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 W 25TH ST
BALTIMORE MD
21218-5002
US

IV. Provider business mailing address

PO BOX 7921
ESSEX MD
21221-0921
US

V. Phone/Fax

Practice location:
  • Phone: 443-682-5807
  • Fax:
Mailing address:
  • Phone: 443-682-5807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCA369
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLC17618
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: