Healthcare Provider Details

I. General information

NPI: 1790372738
Provider Name (Legal Business Name): OLADIPO SOFOLU ADEDEJI MS, LCPC, NCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2020
Last Update Date: 12/23/2020
Certification Date: 12/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8843 GREENBELT RD STE 293
GREENBELT MD
20770-2451
US

IV. Provider business mailing address

1305 KINGSBURY DR
BOWIE MD
20721-2023
US

V. Phone/Fax

Practice location:
  • Phone: 240-297-9857
  • Fax: 240-542-4356
Mailing address:
  • Phone: 202-930-0918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLGP9176
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: