Healthcare Provider Details

I. General information

NPI: 1255792248
Provider Name (Legal Business Name): ELIZABETH OLADOKUN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2016
Last Update Date: 03/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 NICOLE DR
JEFFERSONVILLE IN
47130-8576
US

IV. Provider business mailing address

320 NICOLE DR
JEFFERSONVILLE IN
47130-8576
US

V. Phone/Fax

Practice location:
  • Phone: 615-335-6134
  • Fax:
Mailing address:
  • Phone: 615-335-6134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1120028
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number1120028
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: