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General NPI Number Information
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NPI Number | 1790184182
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Entity Type | Organization
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Legal Business Name | OGBURN COUNSELING SERVICES, LLC
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Dates
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Enumeration Date | 08/21/2014
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Last Update Date | 08/21/2014
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Provider Practice Location Address
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Address Line | 5113 N EXECUTIVE DR STE 101
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City | PEORIA
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State | IL
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Zip | 61614-4884
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Country | US
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Telephone | 309-682-3915
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Fax | 309-679-0703
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Provider Business Mailing Address
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Address Line | 5113 N EXECUTIVE DR STE 101
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City | PEORIA
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State | IL
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Zip | 61614-4884
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Country | US
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Telephone | 309-682-3915
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Fax | 309-679-0703
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Authorized Official
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Title or Position | SOLE MEMBER
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Name | LEIA A OGBURN
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Credential | LCSW
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Telephone | 309-682-3915
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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 | 149-008753
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License Number State | IL
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