Provider Demographics
NPI:1356182943
Name:ODUSANYA, OLUWATOBI A
Entity type:Individual
Prefix:MR
First Name:OLUWATOBI
Middle Name:A
Last Name:ODUSANYA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:953 NEW MARKET ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19123-2314
Mailing Address - Country:US
Mailing Address - Phone:215-715-3193
Mailing Address - Fax:
Practice Address - Street 1:953 NEW MARKET ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19123-2314
Practice Address - Country:US
Practice Address - Phone:215-715-3193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-05
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health