Provider Demographics
NPI:1902562507
Name:POTOMAC SHORES MENTAL HEALTH AND WELLNESS CENTER
Entity Type:Organization
Organization Name:POTOMAC SHORES MENTAL HEALTH AND WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EBUNOLA
Authorized Official - Middle Name:MOIRA
Authorized Official - Last Name:AYOOLA
Authorized Official - Suffix:
Authorized Official - Credentials:PHMNP
Authorized Official - Phone:202-809-3550
Mailing Address - Street 1:13000 HARBOR CENTER DR STE 103
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-2847
Mailing Address - Country:US
Mailing Address - Phone:703-977-6556
Mailing Address - Fax:703-997-1490
Practice Address - Street 1:13000 HARBOR CENTER DR STE 103
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-2847
Practice Address - Country:US
Practice Address - Phone:703-977-6556
Practice Address - Fax:703-997-1490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-09
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)