Healthcare Provider Details

I. General information

NPI: 1710291547
Provider Name (Legal Business Name): OLUFUNKE OMOWUNMI OBATUSIN LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: OLA OMOWUNMI OBATUSIN COUNSELOR

II. Dates (important events)

Enumeration Date: 08/04/2010
Last Update Date: 11/21/2025
Certification Date: 11/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1675 BENNETT ST
UTICA NY
13502-5390
US

IV. Provider business mailing address

1675 BENNETT ST
UTICA NY
13502-5390
US

V. Phone/Fax

Practice location:
  • Phone: 315-624-4801
  • Fax:
Mailing address:
  • Phone: 315-624-4801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number016995
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: