Provider Demographics
NPI:1114916418
Name:OSUNDEKO, TENIOLA O (LCSW, PHD)
Entity Type:Individual
Prefix:MRS
First Name:TENIOLA
Middle Name:O
Last Name:OSUNDEKO
Suffix:
Gender:F
Credentials:LCSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2008 GREEN GLEN DR
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-3216
Mailing Address - Country:US
Mailing Address - Phone:814-746-4174
Mailing Address - Fax:814-746-4174
Practice Address - Street 1:25 E PARK AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-2271
Practice Address - Country:US
Practice Address - Phone:814-591-7169
Practice Address - Fax:814-746-4174
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACWO149201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA094701Medicare ID - Type Unspecified