Provider Demographics
NPI:1720594815
Name:OGUNMOLA, OLASUMBO TEMITAYO
Entity Type:Individual
Prefix:
First Name:OLASUMBO
Middle Name:TEMITAYO
Last Name:OGUNMOLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11601 WHITTIER RD
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-2112
Mailing Address - Country:US
Mailing Address - Phone:240-714-2404
Mailing Address - Fax:
Practice Address - Street 1:11601 WHITTIER RD
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20721-2112
Practice Address - Country:US
Practice Address - Phone:240-714-2404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-27
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDHHA12758374U00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No374U00000XNursing Service Related ProvidersHome Health Aide