Healthcare Provider Details

I. General information

NPI: 1285590612
Provider Name (Legal Business Name): ANGELA RENISHA OMOOGUN LGPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2025
Last Update Date: 12/30/2025
Certification Date: 12/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6212 YORK RD
BALTIMORE MD
21212-2612
US

IV. Provider business mailing address

4724 WINTERSET WAY
OWINGS MILLS MD
21117-4756
US

V. Phone/Fax

Practice location:
  • Phone: 410-878-1085
  • Fax: 443-388-9909
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLGP17375
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: