Healthcare Provider Details

I. General information

NPI: 1285543983
Provider Name (Legal Business Name): OLUKOREDE DANIEL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2026
Last Update Date: 09/07/2026
Certification Date: 09/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6024 HANOVER RD
HANOVER MD
21076-1036
US

IV. Provider business mailing address

6024 HANOVER RD
HANOVER MD
21076-1036
US

V. Phone/Fax

Practice location:
  • Phone: 571-408-9689
  • Fax:
Mailing address:
  • Phone: 571-408-9689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberSC3500
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: