Provider Demographics
NPI:1639263171
Name:OJELADE, IFETAYO I (PHD)
Entity Type:Individual
Prefix:DR
First Name:IFETAYO
Middle Name:I
Last Name:OJELADE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:IYAJOKE
Other - Middle Name:I
Other - Last Name:OJELADE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:505 ANGLER CT SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-8058
Mailing Address - Country:US
Mailing Address - Phone:404-635-6021
Mailing Address - Fax:404-601-7347
Practice Address - Street 1:1867 HARVARD AVE
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30337-3526
Practice Address - Country:US
Practice Address - Phone:404-635-6021
Practice Address - Fax:404-601-7347
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC004532101YP2500X
GAPSY003437103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA708181433AMedicaid