Provider Demographics
NPI:1497358733
Name:ODUGUWA, BRIAN JESSY (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:JESSY
Last Name:ODUGUWA
Suffix:
Gender:M
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1904 14TH ST S
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-4813
Mailing Address - Country:US
Mailing Address - Phone:763-772-7737
Mailing Address - Fax:
Practice Address - Street 1:11812 WAYZATA BLVD STE 200B
Practice Address - Street 2:
Practice Address - City:HOPKINS
Practice Address - State:MN
Practice Address - Zip Code:55305-2012
Practice Address - Country:US
Practice Address - Phone:612-217-2019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-19
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN223501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical