Provider Demographics
NPI:1528667953
Name:OLUSA, GEORGE OLORUNFEMI ADEOLA (CHAPLAIN/PASTOR)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:OLORUNFEMI ADEOLA
Last Name:OLUSA
Suffix:
Gender:M
Credentials:CHAPLAIN/PASTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12301
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85248-0022
Mailing Address - Country:US
Mailing Address - Phone:480-240-0412
Mailing Address - Fax:
Practice Address - Street 1:5651 S MESQUITE GROVE WAY
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85249-9670
Practice Address - Country:US
Practice Address - Phone:480-240-0412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-17
Last Update Date:2020-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD04019037101YP1600X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZD04019037OtherAZ STATE MVD