Healthcare Provider Details

I. General information

NPI: 1366355091
Provider Name (Legal Business Name): YETUNDE DEJA OMITOGUN LGPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 OLNEY SANDY SPRING RD STE 208
SANDY SPRING MD
20860-1075
US

IV. Provider business mailing address

1997 ANNAPOLIS EXCHANGE PKWY STE 300
ANNAPOLIS MD
21401-3273
US

V. Phone/Fax

Practice location:
  • Phone: 410-635-1184
  • Fax: 410-630-8087
Mailing address:
  • Phone: 410-635-1130
  • Fax: 410-630-8087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number200012710
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: