Provider Demographics
NPI:1336647254
Name:OWOLADE, JOY ESE
Entity Type:Individual
Prefix:
First Name:JOY
Middle Name:ESE
Last Name:OWOLADE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JOY
Other - Middle Name:ESE
Other - Last Name:SAMEDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:780 LYNNHAVEN PKWY STE 400
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-7332
Mailing Address - Country:US
Mailing Address - Phone:630-965-0103
Mailing Address - Fax:
Practice Address - Street 1:780 LYNNHAVEN PKWY STE 400
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-7332
Practice Address - Country:US
Practice Address - Phone:630-965-0103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-25
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
VA00002146106S00000X
VARBT-17-36354106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1336647254Medicaid