Healthcare Provider Details

I. General information

NPI: 1790184182
Provider Name (Legal Business Name): OGBURN COUNSELING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2014
Last Update Date: 08/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5113 N EXECUTIVE DR STE 101
PEORIA IL
61614-4884
US

IV. Provider business mailing address

5113 N EXECUTIVE DR STE 101
PEORIA IL
61614-4884
US

V. Phone/Fax

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

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: LEIA A OGBURN
Title or Position: SOLE MEMBER
Credential: LCSW
Phone: 309-682-3915