Healthcare Provider Details

I. General information

NPI: 1194419077
Provider Name (Legal Business Name): MAYOWA OGUNDIYUN LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2023
Last Update Date: 06/05/2023
Certification Date: 09/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8011 MANDAN RD APT 104
GREENBELT MD
20770-2864
US

IV. Provider business mailing address

8011 MANDAN RD APT 104
GREENBELT MD
20770-2864
US

V. Phone/Fax

Practice location:
  • Phone: 240-505-2788
  • Fax:
Mailing address:
  • Phone: 240-505-2788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberA0744
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLC11848
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: