Provider Demographics
NPI:1306191374
Name:WOSU, ANTHONIA MODUPE
Entity Type:Individual
Prefix:MRS
First Name:ANTHONIA
Middle Name:MODUPE
Last Name:WOSU
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:ANTHONIA
Other - Middle Name:MODUPE
Other - Last Name:WOSU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1555 LINCOLN BLVD
Mailing Address - Street 2:
Mailing Address - City:BAYSHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706
Mailing Address - Country:US
Mailing Address - Phone:631-839-5713
Mailing Address - Fax:
Practice Address - Street 1:1555 LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:BAYSHORE
Practice Address - State:NY
Practice Address - Zip Code:11706
Practice Address - Country:US
Practice Address - Phone:631-839-5713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY069662-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker