Healthcare Provider Details

I. General information

NPI: 1407544661
Provider Name (Legal Business Name): PRINCE OWOLIDE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2023
Last Update Date: 04/28/2023
Certification Date: 04/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 W HARRISON ST
CHICAGO IL
60605-1017
US

IV. Provider business mailing address

161 W HARRISON ST
CHICAGO IL
60605-1017
US

V. Phone/Fax

Practice location:
  • Phone: 312-866-3815
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: