Healthcare Provider Details

I. General information

NPI: 1013979897
Provider Name (Legal Business Name): OLATUNJI ABIODUN ODUSANWO LCSW-R
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 08/25/2020
Certification Date: 08/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

465 NEW DORP LN
STATEN ISLAND NY
10306-4902
US

IV. Provider business mailing address

1 EDGEWATER ST SUITE 723
STATEN ISLAND NY
10305-4900
US

V. Phone/Fax

Practice location:
  • Phone: 718-987-0128
  • Fax: 718-987-0223
Mailing address:
  • Phone: 718-226-1008
  • Fax: 718-226-1039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number057740
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number057740
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number057740
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: