Healthcare Provider Details

I. General information

NPI: 1063152965
Provider Name (Legal Business Name): SAMUEL BIDEMI OLOJUGBA RBT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2022
Last Update Date: 03/30/2022
Certification Date: 03/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5017 DENMORE AVE
BALTIMORE MD
21215-5806
US

IV. Provider business mailing address

5017 DENMORE AVE
BALTIMORE MD
21215-5806
US

V. Phone/Fax

Practice location:
  • Phone: 410-301-9718
  • Fax:
Mailing address:
  • Phone: 410-301-9718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-21-196435
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: