Healthcare Provider Details

I. General information

NPI: 1508510819
Provider Name (Legal Business Name): AYOMIDE ADEDAPO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2022
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 YORK RD
LUTHERVILLE MD
21093-6035
US

IV. Provider business mailing address

1301 YORK RD
LUTHERVILLE MD
21093-6035
US

V. Phone/Fax

Practice location:
  • Phone: 716-218-0290
  • Fax:
Mailing address:
  • Phone: 716-218-0290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SL06775200
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number100321
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number111104
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: