1326302670 NPI number — OMOLOLA CHANTELLE OSUNKOYA MA, LPCC

Table of content: OMOLOLA CHANTELLE OSUNKOYA MA, LPCC (NPI 1326302670)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326302670 NPI number — OMOLOLA CHANTELLE OSUNKOYA MA, LPCC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OSUNKOYA
Provider First Name:
OMOLOLA
Provider Middle Name:
CHANTELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, LPCC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
OSUNKOYA
Provider Other First Name:
LOLA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MA, LPCC
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1326302670
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/30/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4779 OSSEO RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55430-3711
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-568-6520
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1710 DOUGLAS DR N STE 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GOLDEN VALLEY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55422-4397
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-568-6520
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/02/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  967 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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