Provider Demographics
NPI:1770464778
Name:OLUFARATI, CORNELIUS
Entity type:Individual
Prefix:
First Name:CORNELIUS
Middle Name:
Last Name:OLUFARATI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 BOWER BLOOM DR
Mailing Address - Street 2:
Mailing Address - City:ROSHARON
Mailing Address - State:TX
Mailing Address - Zip Code:77583-1690
Mailing Address - Country:US
Mailing Address - Phone:832-817-9313
Mailing Address - Fax:
Practice Address - Street 1:110 BOWER BLOOM DR
Practice Address - Street 2:
Practice Address - City:ROSHARON
Practice Address - State:TX
Practice Address - Zip Code:77583-1690
Practice Address - Country:US
Practice Address - Phone:832-817-9313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-08
Last Update Date:2025-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1206232323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility