Provider Demographics
NPI:1215404314
Name:SOREMEKUN, MODUPEOLA OLUREMI (LCASA)
Entity Type:Individual
Prefix:
First Name:MODUPEOLA
Middle Name:OLUREMI
Last Name:SOREMEKUN
Suffix:
Gender:F
Credentials:LCASA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2716 TROXLER RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27215-9187
Mailing Address - Country:US
Mailing Address - Phone:133-657-0010
Mailing Address - Fax:
Practice Address - Street 1:2716 TROXLER RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-9187
Practice Address - Country:US
Practice Address - Phone:336-570-0104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-26
Last Update Date:2018-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-22905101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)