Healthcare Provider Details

I. General information

NPI: 1285026278
Provider Name (Legal Business Name): OLUMIDE OKUNIYI OKUSANYA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2015
Last Update Date: 05/12/2025
Certification Date: 05/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 E GILBERT ST STE 4
SAN BERNARDINO CA
92415-1878
US

IV. Provider business mailing address

PO BOX 1878
RIALTO CA
92377-1878
US

V. Phone/Fax

Practice location:
  • Phone: 909-531-2440
  • Fax:
Mailing address:
  • Phone: 909-458-1505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: