Provider Demographics
NPI:1841944600
Name:OMOYELE, OLUWATOBILOBA D
Entity type:Individual
Prefix:
First Name:OLUWATOBILOBA
Middle Name:D
Last Name:OMOYELE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TOBI
Other - Middle Name:D
Other - Last Name:OMOYELE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:27830 LONG ST
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-2333
Mailing Address - Country:US
Mailing Address - Phone:313-433-8869
Mailing Address - Fax:
Practice Address - Street 1:127 N LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:SOUTH LYON
Practice Address - State:MI
Practice Address - Zip Code:48178-1210
Practice Address - Country:US
Practice Address - Phone:248-573-7417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-09
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6851114527104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker