Healthcare Provider Details

I. General information

NPI: 1528667953
Provider Name (Legal Business Name): GEORGE OLORUNFEMI ADEOLA OLUSA CHAPLAIN/PASTOR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2020
Last Update Date: 10/17/2020
Certification Date: 10/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5651 S MESQUITE GROVE WAY
CHANDLER AZ
85249-9670
US

IV. Provider business mailing address

PO BOX 12301
CHANDLER AZ
85248-0022
US

V. Phone/Fax

Practice location:
  • Phone: 480-240-0412
  • Fax:
Mailing address:
  • Phone: 480-240-0412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberD04019037
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License NumberD04019037
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: