Provider Demographics
NPI:1578173639
Name:OGUNYEMI, MODUPE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MODUPE
Middle Name:
Last Name:OGUNYEMI
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1711 GOLF RD APT 214
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60087-3854
Mailing Address - Country:US
Mailing Address - Phone:618-201-3313
Mailing Address - Fax:
Practice Address - Street 1:1201 N SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-2081
Practice Address - Country:US
Practice Address - Phone:224-303-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-04
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX115300235Z00000X
IL146.015289235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist