Healthcare Provider Details

I. General information

NPI: 1538822317
Provider Name (Legal Business Name): TEMITOPE OLUTADE PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2021
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5359 W FULLERTON AVE
CHICAGO IL
60639-1450
US

IV. Provider business mailing address

120 S MARION ST
OAK PARK IL
60302-2809
US

V. Phone/Fax

Practice location:
  • Phone: 773-836-2785
  • Fax: 773-836-7381
Mailing address:
  • Phone: 773-629-1231
  • Fax: 708-383-7780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209024131
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: