Provider Demographics
NPI:1275062119
Name:OWOYELE, BEVERLY SHAYO (DPT)
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:SHAYO
Last Name:OWOYELE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 LEMON DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76018-1692
Mailing Address - Country:US
Mailing Address - Phone:682-365-4810
Mailing Address - Fax:
Practice Address - Street 1:12005 SUNRISE VALLEY DR STE T40
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-3468
Practice Address - Country:US
Practice Address - Phone:703-860-2391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-05
Last Update Date:2021-07-27
Deactivation Date:2021-04-11
Deactivation Code:
Reactivation Date:2021-07-27
Provider Licenses
StateLicense IDTaxonomies
TX1291086225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist