MEDICARE: OAK LEAF BEHAVIORAL HEALTH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1942822952
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OAK LEAF BEHAVIORAL HEALTH

Provider Business Mailing Address
First Line	:	1600 ELDRIDGE PKWY APT 3607
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77077-1667
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1600 ELDRIDGE PKWY APT 3607
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77077-1667
Country	:	US
Telephone Number	:	832-630-1354
Fax Number	:

Authorized Official
Title or Position	:	OWNER/ CHIEF EXECUTIVE OFFICER
Name	:	EMMANIEL ODINIGWE
Credential	:	PHARM D
Telephone Number	:	832-630-1354

Provider Enumeration Date	:	05/13/2020
Last Update Date	:	05/14/2020

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