Provider Demographics
NPI:1235781600
Name:IYAOMOLERE, DANIEL ADEBOWALE
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:ADEBOWALE
Last Name:IYAOMOLERE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3079 HILL ST
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-5789
Mailing Address - Country:US
Mailing Address - Phone:774-400-3962
Mailing Address - Fax:
Practice Address - Street 1:3079 HILL ST
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-5789
Practice Address - Country:US
Practice Address - Phone:774-400-3962
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 171R00000X, 171W00000X, 172A00000X, 175T00000X, 376K00000X
RI104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No171R00000XOther Service ProvidersInterpreter
No171W00000XOther Service ProvidersContractor
No172A00000XOther Service ProvidersDriver
No175T00000XOther Service ProvidersPeer Specialist
No376K00000XNursing Service Related ProvidersNurse's Aide