Healthcare Provider Details

I. General information

NPI: 1538442744
Provider Name (Legal Business Name): SAM OGUNTADE LCDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2011
Last Update Date: 07/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3840 HULEN ST HTN, CLIENT ACCOUNTING
FORT WORTH TX
76107-7277
US

IV. Provider business mailing address

PO BOX 2603 HTN, CLIENT ACCOUNTING
FORT WORTH TX
76113-2603
US

V. Phone/Fax

Practice location:
  • Phone: 817-569-4300
  • Fax:
Mailing address:
  • Phone: 817-569-4300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number31014
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number12595
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: