Provider Demographics
NPI:1912578196
Name:OLUJIMI, ALICE (RN CADC)
Entity Type:Individual
Prefix:MRS
First Name:ALICE
Middle Name:
Last Name:OLUJIMI
Suffix:
Gender:F
Credentials:RN CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15475 S PARK AVE STE 109
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-1377
Mailing Address - Country:US
Mailing Address - Phone:708-596-5680
Mailing Address - Fax:708-596-5687
Practice Address - Street 1:15475 S PARK AVE STE 109
Practice Address - Street 2:
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-1377
Practice Address - Country:US
Practice Address - Phone:708-596-5680
Practice Address - Fax:708-596-5687
Is Sole Proprietor?:No
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL35095101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL-10.172MMedicaid