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POTOMAC SHORES MENTAL HEALTH & WELLNESS LLC
NPI 1902562507
Nurse Practitioner - Psychiatric/Mental Health in Woodbridge, VA

Active since November 09, 2021CLIA 49D2271025 · Waiver
13000 HARBOR CENTER DR STE 103, WOODBRIDGE, VA 22192(703) 977-6556(703) 997-1490 Get Directions Write a Review

NPPES record last updated: May 2, 2025. Verified against the NPPES registry weekly; last sync: October 18, 2026.

Record update history: Apr 19, 2024, Jan 31, 2023, Nov 24, 2021 and 1 more (4 updates tracked since 2021).

About Potomac Shores Mental Health & Wellness Llc NPPES

Official registry information on file with the National Plan and Provider Enumeration System.

POTOMAC SHORES MENTAL HEALTH & WELLNESS LLC (NPI 1902562507) is a healthcare organization registered as a psychiatric/mental health in Woodbridge, Virginia and active in the NPI registry since November 2021. The organization holds a CLIA Waiver certificate valid through October 25, 2026, maintains 2 additional practice locations, and lists Ebunola Moira Ayoola, Owner, as its authorized official.

NPPES Registry Identity

NPI1902562507
Entity TypeOrganization
Primary Taxonomy363LP0808X
Legal Business NamePOTOMAC SHORES MENTAL HEALTH & WELLNESS LLC
Location Address13000 HARBOR CENTER DR STE 103Woodbridge, VA 22192-2847
Mailing Address13000 Harbor Center Dr Ste 103Woodbridge, VA 22192-2847 · (703) 977-6556 · Fax (703) 997-1490
Phone(703) 977-6556
Fax(703) 997-1490
Organization SubpartNo
Authorized OfficialEbunola Moira AyoolaOwner · (202) 809-3550
Enumeration DateNovember 9, 2021
Last NPPES UpdateMay 2, 20254 updates tracked since enumeration
NPPES CertifiedMay 2, 2025
✔ NPI 1902562507 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses

★ Primary SpecialtyNurse Practitioner · Psychiatric/Mental HealthPhysician Assistants & Advanced Practice Nursing Providers
Taxonomy Code363LP0808X
13000 HARBOR CENTER DR STE 103, Woodbridge, VA 22192
Open in Google Maps ↗

Secondary Practice Locations 2

Location 17777 Leesburg Pike Ste 305SFalls Church, VA 22043-2443 · Phone (703) 977-6556 · Fax (703) 997-1490
Location 21401 21st St # 7927Sacramento, CA 95811-5226 · Phone (888) 602-4957

Group Practice 1

Group TaxonomyThis provider is a business group of one or more individual practitioners, who practice with different areas of specialization.193200000X MULTI-SPECIALTY GROUP

Medicare Participation & PECOS CMS

Medicare enrollment and the clinicians who bill Medicare through this organization, from CMS.

Medicare Enrollment Status

✔

Enrolled in Medicare (PECOS)

Potomac Shores Mental Health & Wellness Llc is registered in the CMS Provider Enrollment, Chain and Ownership System (PECOS).

Clinicians Billing Medicare Through This Organization

7

Medicare enrollment records show 7 clinicians reassign Medicare billing to Potomac Shores Mental Health & Wellness LLC, which bills Medicare for the services they deliver. Of these, 2 practice at this address and 3 within 10 miles. They are listed nearest first.

Clinicians, nearest first (7)

Ebunola Ayoola-Yussuf, PMHNP
Nurse Practitioner
NPI 1497938849
13000 HARBOR CENTER DR STE 103
Woodbridge, VA 22192
(703) 977-6556
✔ PECOS✔ Accepts MedicareSame address
Olga Wymore
Nurse Practitioner
NPI 1528858859
13000 HARBOR CENTER DR STE 103
Woodbridge, VA 22192
(804) 982-4370
✔ PECOS✔ Accepts MedicareSame address
Chika Okeoma, NP
Nurse Practitioner
NPI 1508604737
3763 FETTLER PARK DR
Dumfries, VA 22025
(571) 621-3202
✔ PECOS✔ Accepts Medicare7.6 mi
Eveline Fohtung, NP
Nurse Practitioner
NPI 1649004979
11 SMOKEHOUSE DR
Fredericksburg, VA 22406
(571) 762-9099
✔ PECOS✔ Accepts Medicare26 mi
Theresa Boakye, PMHNP
Nurse Practitioner
NPI 1326819673
109 ABBY LN
Fredericksburg, VA 22405
(703) 589-3024
✔ PECOS✔ Accepts Medicare27 mi
Anais Schultz
Nurse Practitioner
NPI 1023870243
1320 CENTRAL PARK BLVD STE 200
Fredericksburg, VA 22401
(571) 317-1386
✔ PECOS29 mi
Theresa Buabeng, PMHNP
Nurse Practitioner
NPI 1568253912
1417 WINTER PINE TRL
Severn, MD 21144
(571) 251-8494
✔ PECOS✔ Accepts Medicare43 mi

Source: CMS Revalidation Reassignment List, October 2026 release. Reassignment records can lag staffing changes; confirm a current affiliation with the organization.

CLIA Laboratory Certificates CMS CLIA

Laboratory certificates issued under the Clinical Laboratory Improvement Amendments (CLIA) program, which sets federal quality standards for human laboratory testing in the United States. There is no official CMS crosswalk between CLIA and NPI numbers; these certificates are associated with this NPI by matching facility names, locations and phone numbers in the CMS CLIA registry.

Certificate of Waiver 49D2271025

Potomac Shores Mental Health And Wellness · Woodbridge, VA
Active · expires Oct 25, 2026
CLIA Number49D2271025
Laboratory TypePractitioner Other
Certificate Effective DateOctober 26, 2024
Certificate Expiration DateOctober 25, 2026
Laboratory DirectorEbunola Ayoola-Yussuf
Laboratory Phone(703) 977-6556
Laboratory LocationPotomac Shores Mental Health And Wellness13000 Harbor Center Dr, Ste 103, Woodbridge, VA 22192
CLIA data matches this NPI record on: Address Phone
This certificate is issued to a laboratory to perform only waived tests.

Frequently Asked Questions NPPES & CMS

Common questions about this NPI record, answered from the official NPPES registry and CMS datasets shown on this page.

What is Potomac Shores Mental Health & Wellness LLC's NPI number?

The NPI number for Potomac Shores Mental Health & Wellness LLC is 1902562507. It was assigned to this organization in the NPPES registry on November 9, 2021.

Where is Potomac Shores Mental Health & Wellness LLC located?

Potomac Shores Mental Health & Wellness LLC is located at 13000 Harbor Center Dr Ste 103, Woodbridge, VA 22192. The listed phone number is (703) 977-6556.

What is Potomac Shores Mental Health & Wellness LLC's specialty?

The primary specialty registered for this NPI is Nurse Practitioner, specializing in Psychiatric/Mental Health, with taxonomy code 363LP0808X.

Is Potomac Shores Mental Health & Wellness LLC enrolled in Medicare?

Yes. Potomac Shores Mental Health & Wellness LLC is registered in the Medicare PECOS enrollment system.

How many clinicians bill Medicare through Potomac Shores Mental Health & Wellness LLC?

According to the CMS Revalidation Reassignment List (October 2026 release), 7 clinicians, all in Nurse Practitioner, reassign their Medicare billing to Potomac Shores Mental Health & Wellness LLC. A reassignment is filed with Medicare on form CMS-855R, signed by both the clinician and the organization, and lets the organization bill Medicare and receive payment for the clinician's services. Of these, 2 practice at this address and 3 within 10 miles. Reassignment records can lag staffing changes; confirm a current affiliation with the organization.

Does Potomac Shores Mental Health & Wellness LLC hold a CLIA laboratory certificate?

Yes. A Certificate of Waiver (number 49D2271025) is associated with this NPI, valid through October 25, 2026. CLIA certificates authorize laboratory testing under the federal Clinical Laboratory Improvement Amendments program.

When was this NPI record last updated?

The NPPES record for Potomac Shores Mental Health & Wellness LLC was last updated on May 2, 2025. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 17 months ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.