Healthcare Provider Details

I. General information

NPI: 1053230458
Provider Name (Legal Business Name): IFEOLUWA SAMUEL ADEYEMO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2026
Last Update Date: 07/11/2026
Certification Date: 07/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11571 LAURELWALK DR
LAUREL MD
20708-3001
US

IV. Provider business mailing address

11571 LAURELWALK DR
LAUREL MD
20708-3001
US

V. Phone/Fax

Practice location:
  • Phone: 240-646-2801
  • Fax:
Mailing address:
  • Phone: 240-646-2801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: