Provider Demographics
NPI:1114652138
Name:EBODA, OLAITAN ADESOLA (PMHNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:OLAITAN
Middle Name:ADESOLA
Last Name:EBODA
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 CHURCH RD STE 219
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08002-1460
Mailing Address - Country:US
Mailing Address - Phone:732-372-5963
Mailing Address - Fax:
Practice Address - Street 1:811 CHURCH RD STE 219
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08002-1460
Practice Address - Country:US
Practice Address - Phone:732-372-5963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-22
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ013437002084P0802X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Single Specialty