Healthcare Provider Details

I. General information

NPI: 1275438244
Provider Name (Legal Business Name): SOUTH SHORE PSYCHIATRY AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2026
Last Update Date: 10/10/2026
Certification Date: 10/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 HOLIDAY PLAZA DR STE 182B
MATTESON IL
60443-2236
US

IV. Provider business mailing address

600 HOLIDAY PLAZA DR STE 182B
MATTESON IL
60443-2236
US

V. Phone/Fax

Practice location:
  • Phone: 312-650-9685
  • Fax:
Mailing address:
  • Phone: 312-650-9685
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ADELINE OGBOR
Title or Position: CEO
Credential: PMHNP-BC
Phone: 312-650-9685