Provider Demographics
NPI:1972950343
Name:ADEWAKUN, MARYANNE
Entity Type:Individual
Prefix:
First Name:MARYANNE
Middle Name:
Last Name:ADEWAKUN
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 1:4027 CHARIOT CIRCLE SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080
Mailing Address - Country:US
Mailing Address - Phone:404-790-6527
Mailing Address - Fax:
Practice Address - Street 1:4027 CHARIOT CIR SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-5774
Practice Address - Country:US
Practice Address - Phone:404-790-6527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-16
Last Update Date:2017-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA008942101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health