Healthcare Provider Details

I. General information

NPI: 1467783811
Provider Name (Legal Business Name): LESLY THREADGILL OGUNGBEMI MSW - LCSW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2010
Last Update Date: 06/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3525H ELLICOTT MILLS DR STE 108
ELLICOTT CITY MD
21043-4544
US

IV. Provider business mailing address

3525H ELLICOTT MILLS DR STE 108
ELLICOTT CITY MD
21043-4544
US

V. Phone/Fax

Practice location:
  • Phone: 410-212-0111
  • Fax:
Mailing address:
  • Phone: 410-212-0111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number03868
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: