Provider Demographics
NPI:1841997889
Name:AGWANIHU, OBRAIN U
Entity type:Individual
Prefix:MR
First Name:OBRAIN
Middle Name:U
Last Name:AGWANIHU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 BIXLEY HEATH
Mailing Address - Street 2:
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-3140
Mailing Address - Country:US
Mailing Address - Phone:516-574-1018
Mailing Address - Fax:
Practice Address - Street 1:622 DAVIS ST STE 200
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4491
Practice Address - Country:US
Practice Address - Phone:773-294-0176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-09
Last Update Date:2024-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.110303104100000X
IL149.0276281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker