Healthcare Provider Details

I. General information

NPI: 1982370383
Provider Name (Legal Business Name): OLANREWAJU SHOTUNDE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2021
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5850 MERCURY DR STE 280
DEARBORN MI
48126-2980
US

IV. Provider business mailing address

27777 INKSTER RD STE 100
FARMINGTON HILLS MI
48334-5312
US

V. Phone/Fax

Practice location:
  • Phone: 248-436-4355
  • Fax:
Mailing address:
  • Phone: 248-436-4355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number7401003396
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: