Provider Demographics
NPI:1538821319
Name:LAWAL, OMOLOLA SOLAPE
Entity type:Individual
Prefix:
First Name:OMOLOLA
Middle Name:SOLAPE
Last Name:LAWAL
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 1:2605 BINGHAMTON LN
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61705-6509
Mailing Address - Country:US
Mailing Address - Phone:217-828-0962
Mailing Address - Fax:
Practice Address - Street 1:706 OGLESBY AVE STE 110
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-4616
Practice Address - Country:US
Practice Address - Phone:217-828-0962
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-09
Last Update Date:2021-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.017182101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health