Provider Demographics
NPI:1144843129
Name:OGUNMODEDE, MOBOLAJI KAZEEM (COTA)
Entity type:Individual
Prefix:
First Name:MOBOLAJI
Middle Name:KAZEEM
Last Name:OGUNMODEDE
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 E 191ST PL APT 710
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60425-1934
Mailing Address - Country:US
Mailing Address - Phone:847-532-8152
Mailing Address - Fax:
Practice Address - Street 1:3320 TALL GRASS DR
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60564-4445
Practice Address - Country:US
Practice Address - Phone:770-312-1003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-25
Last Update Date:2025-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.005212224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant