# POTOMAC SHORES MENTAL HEALTH & WELLNESS LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1902562507
- **Authorized official:** EBUNOLA MOIRA AYOOLA PHMNP (OWNER)
- **Authorized official phone:** (202) 809-3550

## Contact information

- **Practice address:** 13000 HARBOR CENTER DR STE 103, WOODBRIDGE, VA 22192-2847
- **Practice address phone:** (703) 977-6556
- **Practice address fax:** (703) 997-1490
- **Mailing address:** 13000 HARBOR CENTER DR STE 103, WOODBRIDGE, VA 22192-2847
- **Mailing address phone:** (703) 977-6556
- **Mailing address fax:** (703) 997-1490

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 363LP0808X | Psychiatric/Mental Health Nurse Practitioner | — | NULL | Yes |
| 363LP0808X | Psychiatric/Mental Health Nurse Practitioner | — | — | Yes |

## Other

- **Enumeration date:** 11/09/2021
- **Last updated:** 05/02/2025