Healthcare Provider Details

I. General information

NPI: 1053285072
Provider Name (Legal Business Name): OMOBOLANLE GLORIA WUNUKEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2025
Last Update Date: 10/02/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1815 MEDITERRANEAN DR
SYCAMORE IL
60178-3299
US

IV. Provider business mailing address

1075 RIDGE DR APT 8
DEKALB IL
60115-1307
US

V. Phone/Fax

Practice location:
  • Phone: 815-787-9000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178.022154
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: