Provider Demographics
NPI:1447943154
Name:OLUSOLA, THERESA (PMHNP)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:OLUSOLA
Suffix:
Gender:
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 175TH ST STE 6
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-2077
Mailing Address - Country:US
Mailing Address - Phone:708-715-7440
Mailing Address - Fax:708-365-2949
Practice Address - Street 1:920 175TH ST STE 6
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-2077
Practice Address - Country:US
Practice Address - Phone:708-715-7440
Practice Address - Fax:708-365-2949
Is Sole Proprietor?:No
Enumeration Date:2023-05-30
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.027525363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health