Provider Demographics
NPI:1659941243
Name:OLAWORE, MISTURA ABIDEMI
Entity Type:Individual
Prefix:
First Name:MISTURA
Middle Name:ABIDEMI
Last Name:OLAWORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MISITURA
Other - Middle Name:ABIDEMI
Other - Last Name:OLAWORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5820 N KENMORE AVE APT 106
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-3701
Mailing Address - Country:US
Mailing Address - Phone:847-986-0981
Mailing Address - Fax:
Practice Address - Street 1:655 W IRVING PARK RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-3123
Practice Address - Country:US
Practice Address - Phone:773-304-8723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-28
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YM0800X, 101YP2500X
IL178017396101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health