Healthcare Provider Details

I. General information

NPI: 1124847447
Provider Name (Legal Business Name): EALA O'SE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2024
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5215 N CALIFORNIA AVE STE F101
CHICAGO IL
60625-0035
US

IV. Provider business mailing address

6544 N ASHLAND AVE APT 3S
CHICAGO IL
60626-6679
US

V. Phone/Fax

Practice location:
  • Phone: 773-561-5809
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: