Provider Demographics
NPI:1154946770
Name:AKINWALE, IBUKUN MICHELLE
Entity type:Individual
Prefix:
First Name:IBUKUN
Middle Name:MICHELLE
Last Name:AKINWALE
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 1:3056 N GRESHAM AVE UNIT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-6709
Mailing Address - Country:US
Mailing Address - Phone:773-399-9320
Mailing Address - Fax:
Practice Address - Street 1:3056 N GRESHAM AVE UNIT 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-6709
Practice Address - Country:US
Practice Address - Phone:773-399-9320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-09
Last Update Date:2023-12-14
Deactivation Date:2021-05-20
Deactivation Code:
Reactivation Date:2023-12-14
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician