Provider Demographics
NPI:1043095326
Name:ORIBAMISE, OJO STEPHEN
Entity Type:Individual
Prefix:
First Name:OJO
Middle Name:STEPHEN
Last Name:ORIBAMISE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2119 110TH LN NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-4173
Mailing Address - Country:US
Mailing Address - Phone:612-456-6090
Mailing Address - Fax:
Practice Address - Street 1:6217 65TH AVE N APT 304
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55429-1945
Practice Address - Country:US
Practice Address - Phone:651-404-5620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-25
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10251995103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist