Provider Demographics
NPI:1689083867
Name:EDEMODU, OLUMIDE (BCBA)
Entity Type:Individual
Prefix:
First Name:OLUMIDE
Middle Name:
Last Name:EDEMODU
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2788 DEFOORS FERRY RD NW APT 85
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-2150
Mailing Address - Country:US
Mailing Address - Phone:646-251-0799
Mailing Address - Fax:
Practice Address - Street 1:2788 DEFOORS FERRY RD NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30318-2182
Practice Address - Country:US
Practice Address - Phone:646-251-0799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-13-14409103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst