Healthcare Provider Details

I. General information

NPI: 1366715476
Provider Name (Legal Business Name): ELI ELLIS OGBURN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2012
Last Update Date: 01/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 12TH AVE E
SEATTLE WA
98102-5806
US

IV. Provider business mailing address

202 12TH AVE E
SEATTLE WA
98102-5806
US

V. Phone/Fax

Practice location:
  • Phone: 919-599-2813
  • Fax:
Mailing address:
  • Phone: 919-599-2813
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC008570
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW60681605
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: