Basic Information
| Provider Information | |||||||||
| NPI: | 1134763378 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | USMAN | ||||||||
| FirstName: | IDRIS | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | OGUNJOBI | ||||||||
| OtherFirstName: | IDRIS | ||||||||
| OtherMiddleName: | BOLA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1060 GAFFNEY RD STOP 7440 | ||||||||
| Address2: | |||||||||
| City: | FT WAINWRIGHT | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997035007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073615603 | ||||||||
| FaxNumber: | 9073614847 | ||||||||
| Practice Location | |||||||||
| Address1: | 786 D ST. | ||||||||
| Address2: | |||||||||
| City: | JBER-RICHARDSON | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073840405 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2019 | ||||||||
| LastUpdateDate: | 10/31/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 4452 | HI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.