Healthcare Provider Details

I. General information

NPI: 1902536279
Provider Name (Legal Business Name): EBUNOLUWA ABODUNRIN OGUNOLA PHYSICAL THERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2022
Last Update Date: 10/09/2025
Certification Date: 10/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3020 E BROAD ST STE 112
MANSFIELD TX
76063-6696
US

IV. Provider business mailing address

2122 YORK RD STE 300
OAK BROOK IL
60523-1925
US

V. Phone/Fax

Practice location:
  • Phone: 682-422-7580
  • Fax:
Mailing address:
  • Phone: 630-575-1980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1360654
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: