Healthcare Provider Details

I. General information

NPI: 1346022290
Provider Name (Legal Business Name): OMOYENI AYOBAMI OYEDERU LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2023
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 CENTRACARE CIR
SAINT CLOUD MN
56303-5000
US

IV. Provider business mailing address

1613 CEDAR KNOLL PL
SAINT CLOUD MN
56301-5727
US

V. Phone/Fax

Practice location:
  • Phone: 320-229-4945
  • Fax: 320-229-5179
Mailing address:
  • Phone: 612-355-9682
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCC04154
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: