MEDICARE: GOLDENMEMORY MENTAL HEALTH AND BEHAVIORAL SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1538925961
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOLDENMEMORY MENTAL HEALTH AND BEHAVIORAL SERVICES

Provider Business Mailing Address
First Line	:	1055 TAYLOR AVE STE 208
Second Line	:
City	:	TOWSON
State	:	MD
Zip	:	21286-8333
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1055 TAYLOR AVE STE 208
Second Line	:
City	:	TOWSON
State	:	MD
Zip	:	21286-8333
Country	:	US
Telephone Number	:	410-404-9661
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SOLOMON ADEKOLA
Credential	:
Telephone Number	:	443-642-1218

Provider Enumeration Date	:	02/23/2024
Last Update Date	:	10/03/2024

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