Provider Demographics
NPI:1841037728
Name:OMEGA BEHAVIORAL CLINIC LLC
Entity type:Organization
Organization Name:OMEGA BEHAVIORAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTIONER
Authorized Official - Prefix:
Authorized Official - First Name:OLUFUNKE
Authorized Official - Middle Name:
Authorized Official - Last Name:TAIWO
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:301-520-6782
Mailing Address - Street 1:1202 NORTHERN LIGHTS DR
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-6049
Mailing Address - Country:US
Mailing Address - Phone:301-520-6782
Mailing Address - Fax:
Practice Address - Street 1:4500 FORBES BLVD STE 200
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-6316
Practice Address - Country:US
Practice Address - Phone:301-520-6782
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-09
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty