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General NPI Number Information
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NPI Number | 1538442744
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Entity Type | Individual
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Provider Name | SAM OGUNTADE LCDC
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Gender | Male
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Dates
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Enumeration Date | 09/23/2011
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Last Update Date | 07/31/2015
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Provider Practice Location Address
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Address Line | 3840 HULEN ST HTN, CLIENT ACCOUNTING
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City | FORT WORTH
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State | TX
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Zip | 76107-7277
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Country | US
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Telephone | 817-569-4300
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2603 HTN, CLIENT ACCOUNTING
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City | FORT WORTH
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State | TX
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Zip | 76113-2603
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Country | US
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Telephone | 817-569-4300
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 31014
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 12595
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License Number State | TX
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