Healthcare Provider Details

I. General information

NPI: 1891454922
Provider Name (Legal Business Name): EKE OKUSANYA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2021
Last Update Date: 12/16/2021
Certification Date: 12/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3933 HARRISON ST
RIVERSIDE CA
92503-3523
US

IV. Provider business mailing address

3933 HARRISON ST
RIVERSIDE CA
92503-3523
US

V. Phone/Fax

Practice location:
  • Phone: 833-391-0505
  • Fax:
Mailing address:
  • Phone: 833-391-0505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number42071
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: