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

Q: 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.

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: August 16, 2026.

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

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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

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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

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.

Other Providers at the Same Location NPPES 2

Providers registered at the same practice address, or within the immediate area, according to the NPPES registry.

EBUNOLA M AYOOLA-YUSSUF PMHNP

Nurse Practitioner (Psychiatric/Mental Health)

13000 HARBOR CENTER DR STE 103
WOODBRIDGE, VA 22192

Prince William County (703) 977-6556

OLGA VLADIMIROVNA WYMORE

Nurse Practitioner (Psychiatric/Mental Health)

13000 HARBOR CENTER DR STE 103
WOODBRIDGE, VA 22192

Prince William County (804) 982-4370

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.

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 15 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.