Basic Information
| Provider Information | |||||||||
| NPI: | 1013979897 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ODUSANWO | ||||||||
| FirstName: | OLATUNJI | ||||||||
| MiddleName: | ABIODUN | ||||||||
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| Credential: | LCSW-R | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 EDGEWATER ST | ||||||||
| Address2: | SUITE 723 | ||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103054900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182261008 | ||||||||
| FaxNumber: | 7182261039 | ||||||||
| Practice Location | |||||||||
| Address1: | 465 NEW DORP LN | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103064902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189870128 | ||||||||
| FaxNumber: | 7189870223 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2006 | ||||||||
| LastUpdateDate: | 08/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 057740 | NY | N | Behavioral Health & Social Service Providers | Social Worker | 1041S0200X | 057740 | NY | N | Behavioral Health & Social Service Providers | Social Worker | School | 1041C0700X | 057740 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 02167866 | 05 | NY | MEDICAID |