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General NPI Number Information
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NPI Number | 1871137638
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Entity Type | Individual
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Provider Name | OMOLOLA VICTORIA IMANI MA, LCPC
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Gender | Female
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Dates
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Enumeration Date | 11/04/2019
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Last Update Date | 03/07/2022
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Provider Practice Location Address
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Address Line | 2225 N CHARLES ST
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City | BALTIMORE
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State | MD
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Zip | 21218-5778
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Country | US
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Telephone | 410-453-9553
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Fax |
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Provider Business Mailing Address
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Address Line | 7603 CHERT CT
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City | GLEN BURNIE
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State | MD
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Zip | 21060-8741
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Country | US
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Telephone | 301-806-8012
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LGPC00489
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License Number State | DC
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LGP9449
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License Number State | MD
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Taxonomy #3
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LC12182
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License Number State | MD
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