Provider Demographics
NPI:1548067648
Name:SOMOYE, KEHINDE ADISA
Entity type:Individual
Prefix:
First Name:KEHINDE
Middle Name:ADISA
Last Name:SOMOYE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:295 WORTH AVE # 1073
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22556-1596
Mailing Address - Country:US
Mailing Address - Phone:540-251-9664
Mailing Address - Fax:540-374-2024
Practice Address - Street 1:295 WORTH AVE # 1073
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22556-1596
Practice Address - Country:US
Practice Address - Phone:540-251-9664
Practice Address - Fax:540-374-2024
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-26
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-25-414728106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty