Provider Demographics
NPI:1154092005
Name:OGLESBAY, SCOTT (LMT, MMT, BCTMB)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:OGLESBAY
Suffix:
Gender:M
Credentials:LMT, MMT, BCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:454 BLAKE AVE SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30316-1720
Mailing Address - Country:US
Mailing Address - Phone:617-571-8684
Mailing Address - Fax:
Practice Address - Street 1:454 BLAKE AVE SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30316-1720
Practice Address - Country:US
Practice Address - Phone:404-937-6234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9989225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist