Healthcare Provider Details

I. General information

NPI: 1659963171
Provider Name (Legal Business Name): VIDAH AWINO OTIENO LCSWA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2021
Last Update Date: 02/05/2021
Certification Date: 02/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2706 SAINT JUDE ST
GREENSBORO NC
27405-3670
US

IV. Provider business mailing address

2706 SAINT JUDE ST
GREENSBORO NC
27405-3670
US

V. Phone/Fax

Practice location:
  • Phone: 336-674-9781
  • Fax: 336-282-3430
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP015691
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: