Provider Demographics
NPI:1164201729
Name:IKUOMOLA, OLUWASEUN PATIENCE
Entity Type:Individual
Prefix:
First Name:OLUWASEUN
Middle Name:PATIENCE
Last Name:IKUOMOLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19525 NORDHOFF ST APT 630
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91324-7429
Mailing Address - Country:US
Mailing Address - Phone:310-297-0495
Mailing Address - Fax:
Practice Address - Street 1:3655 TORRANCE BLVD STE 300
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-4857
Practice Address - Country:US
Practice Address - Phone:424-844-0109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA139136101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health