Healthcare Provider Details

I. General information

NPI: 1679807234
Provider Name (Legal Business Name): OLIVER OGBONNA LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2009
Last Update Date: 09/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 BENJAMIN LANE
CORDTLAND MANOR NY
10567
US

IV. Provider business mailing address

8 BENJAMIN LN
CORTLANDT MANOR NY
10567-6742
US

V. Phone/Fax

Practice location:
  • Phone: 917-701-4329
  • Fax:
Mailing address:
  • Phone: 917-701-4329
  • Fax: 718-588-5704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number0519121
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number075141
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: