Provider Demographics
NPI:1225661424
Name:EGONMWAN IDUBOR, OSATO (LICSW)
Entity type:Individual
Prefix:
First Name:OSATO
Middle Name:
Last Name:EGONMWAN IDUBOR
Suffix:
Gender:
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 MAIN ST APT 415
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-4051
Mailing Address - Country:US
Mailing Address - Phone:178-163-2839
Mailing Address - Fax:
Practice Address - Street 1:1268 BROADWAY
Practice Address - Street 2:
Practice Address - City:SAUGUS
Practice Address - State:MA
Practice Address - Zip Code:01906-4709
Practice Address - Country:US
Practice Address - Phone:301-337-7298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-16
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALICSW1245581041C0700X
VA09040158941041C0700X
DCLC2000025411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical