Healthcare Provider Details

I. General information

NPI: 1942362405
Provider Name (Legal Business Name): ROSS OLDENBURG M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 E CEDAR AVE
GLADWIN MI
48624-2215
US

IV. Provider business mailing address

655 E CEDAR AVE
GLADWIN MI
48624-2215
US

V. Phone/Fax

Practice location:
  • Phone: 989-426-9295
  • Fax: 989-426-2251
Mailing address:
  • Phone: 989-426-9295
  • Fax: 989-426-2251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301006898
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: