Healthcare Provider Details

I. General information

NPI: 1396551693
Provider Name (Legal Business Name): OLAYINKA M OLANREWAJU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

1425 BUCKLAND CT
AVON IN
46123-5592
US

IV. Provider business mailing address

1425 BUCKLAND CT
AVON IN
46123-5592
US

V. Phone/Fax

Practice location:
  • Phone: 317-499-1287
  • Fax:
Mailing address:
  • Phone: 317-499-1287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number24017404
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: