Provider Demographics
NPI:1154876415
Name:FADEYI, AYOOLA
Entity type:Individual
Prefix:
First Name:AYOOLA
Middle Name:
Last Name:FADEYI
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 1:1446 BELLSMITH DR
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-0921
Mailing Address - Country:US
Mailing Address - Phone:917-445-2420
Mailing Address - Fax:
Practice Address - Street 1:1446 BELLSMITH DR
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-0921
Practice Address - Country:US
Practice Address - Phone:917-445-2420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-16
Last Update Date:2024-11-05
Deactivation Date:2020-08-07
Deactivation Code:
Reactivation Date:2024-11-05
Provider Licenses
StateLicense IDTaxonomies
GA34147225C00000X
GA055852853347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
No347C00000XTransportation ServicesPrivate Vehicle