=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780198192
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BAYO BABATUNDE AGBOLADE PMHNP-BC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2017
-----------------------------------------------------
Last Update Date | 01/15/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4711 MIDLOTHIAN TPKE STE 14
-----------------------------------------------------
City | CRESTWOOD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60418-4903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 779-910-8196
-----------------------------------------------------
Fax | 708-963-0105
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4711 MIDLOTHIAN TPKE STE 14
-----------------------------------------------------
City | CRESTWOOD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60418-4903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-743-2714
-----------------------------------------------------
Fax | 708-963-0105
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 277004414
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------