Healthcare Provider Details

I. General information

NPI: 1558370700
Provider Name (Legal Business Name): LEIA A OGBURN L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 12/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4719 N SHERIDAN RD
PEORIA IL
61614-5925
US

IV. Provider business mailing address

24851 SPRING CREEK RD
WASHINGTON IL
61571-9659
US

V. Phone/Fax

Practice location:
  • Phone: 309-682-3915
  • Fax: 309-679-0703
Mailing address:
  • Phone: 309-219-5217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149-008753
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: