Provider Demographics
NPI:1366949968
Name:IPADEOLA, TITI A
Entity type:Individual
Prefix:DR
First Name:TITI
Middle Name:A
Last Name:IPADEOLA
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:PO BOX 1245
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-8245
Mailing Address - Country:US
Mailing Address - Phone:770-865-9118
Mailing Address - Fax:
Practice Address - Street 1:205 N MAIN ST
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-3224
Practice Address - Country:US
Practice Address - Phone:770-865-9118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-10
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004963101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA034664765OtherDRIVER'S LICENSE