Provider Demographics
NPI:1073989844
Name:OGLESBY, GLEN (MA LADC)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:
Last Name:OGLESBY
Suffix:
Gender:M
Credentials:MA LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:366 PRIOR AVE N
Mailing Address - Street 2:SUITE 204
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-5165
Mailing Address - Country:US
Mailing Address - Phone:651-644-4944
Mailing Address - Fax:651-646-0196
Practice Address - Street 1:366 PRIOR AVE N
Practice Address - Street 2:SUITE 204
Practice Address - City:ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-5165
Practice Address - Country:US
Practice Address - Phone:651-644-4944
Practice Address - Fax:651-646-0196
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-17
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303172101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)