Provider Demographics
NPI:1750724324
Name:OMODUNNI, WANDA S (LCSW-A)
Entity type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:S
Last Name:OMODUNNI
Suffix:
Gender:F
Credentials:LCSW-A
Other - Prefix:MRS
Other - First Name:WANDA
Other - Middle Name:
Other - Last Name:RENFROW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:PO BOX 2053
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-2053
Mailing Address - Country:US
Mailing Address - Phone:910-498-9848
Mailing Address - Fax:
Practice Address - Street 1:202 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:NC
Practice Address - Zip Code:28372-5040
Practice Address - Country:US
Practice Address - Phone:910-491-9848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-12
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 1041C0700X
NCP0065271041C0700X
NC1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC405127Medicaid
SC405127Medicaid