=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659023414
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PSYCHE & SOMA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2022
-----------------------------------------------------
Last Update Date | 08/29/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1002 E CAPITOL ST NE
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20003-3906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-552-1741
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1001 E CAPITOL ST SE
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20003-3905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-552-1741
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | DR. AURELIO OGILVIE
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 202-552-1741
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------