Basic Information
Provider Information | |||||||||
NPI: | 1780349365 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | OLORUNNISOMO | ||||||||
FirstName: | MORENIKE | ||||||||
MiddleName: | NAOMI SALONE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPC-ASSOCIATE | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2410 MYSTIC TRL | ||||||||
Address2: |   | ||||||||
City: | ROWLETT | ||||||||
State: | TX | ||||||||
PostalCode: | 750882428 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2146160084 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2451 STONE MYERS PKWY | ||||||||
Address2: |   | ||||||||
City: | GRAPEVINE | ||||||||
State: | TX | ||||||||
PostalCode: | 760514782 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8179061111 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/08/2021 | ||||||||
LastUpdateDate: | 11/08/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/08/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 85260 | TX | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.