Provider Demographics
NPI:1144666090
Name:ONUMAH-ONIKORO, GWENDOLYN (LICSW)
Entity type:Individual
Prefix:MS
First Name:GWENDOLYN
Middle Name:
Last Name:ONUMAH-ONIKORO
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2265 YOUNGMAN AVE APT 105E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116-4400
Mailing Address - Country:US
Mailing Address - Phone:612-414-7314
Mailing Address - Fax:
Practice Address - Street 1:8040 OLD CEDAR AVE S STE 101
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55425-1211
Practice Address - Country:US
Practice Address - Phone:952-992-9803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-20
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11184101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNF68290Medicare UPIN