Healthcare Provider Details

I. General information

NPI: 1366936767
Provider Name (Legal Business Name): AJIBOLA A OBAJIMI LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2018
Last Update Date: 10/30/2020
Certification Date: 10/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1133 E 83RD ST UNIT 172
CHICAGO IL
60619-6400
US

IV. Provider business mailing address

1133 E 83RD ST UNIT 172
CHICAGO IL
60619-6400
US

V. Phone/Fax

Practice location:
  • Phone: 312-305-1007
  • Fax: 773-207-5335
Mailing address:
  • Phone: 312-305-1007
  • Fax: 773-207-5335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180011550
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: