Provider Demographics
NPI:1265059703
Name:OMISAKIN, ADEMOLA CLEMENT JR (LGPC)
Entity type:Individual
Prefix:
First Name:ADEMOLA
Middle Name:CLEMENT
Last Name:OMISAKIN
Suffix:JR
Gender:M
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10900 WHARTON DR
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-1469
Mailing Address - Country:US
Mailing Address - Phone:240-544-8610
Mailing Address - Fax:
Practice Address - Street 1:5900 PRINCESS GARDEN PKWY
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-2925
Practice Address - Country:US
Practice Address - Phone:301-851-5954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-01
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP10524101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD84-2094162Medicaid