Provider Demographics
NPI:1104502970
Name:SHODEINDE, KHADIJAT MORENIKE IBUKUN
Entity type:Individual
Prefix:
First Name:KHADIJAT
Middle Name:MORENIKE IBUKUN
Last Name:SHODEINDE
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 1:3551 CATSKILL ST
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603
Mailing Address - Country:US
Mailing Address - Phone:804-245-1967
Mailing Address - Fax:
Practice Address - Street 1:11200 WAPLES MILL RD UNIT 100
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030
Practice Address - Country:US
Practice Address - Phone:703-237-2219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician