Provider Demographics
NPI: | 1376049866 |
---|---|
Name: | OGUNDELE, OLUSEGUN JOSEPH |
Entity Type: | Individual |
Prefix: | |
First Name: | OLUSEGUN |
Middle Name: | JOSEPH |
Last Name: | OGUNDELE |
Suffix: | |
Gender: | M |
Credentials: | |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 14801 E 18TH PL |
Mailing Address - Street 2: | |
Mailing Address - City: | AURORA |
Mailing Address - State: | CO |
Mailing Address - Zip Code: | 80011-4480 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 791 CHAMBER ZONE 3RD FLOOR |
Practice Address - Street 2: | |
Practice Address - City: | AURORA |
Practice Address - State: | CO |
Practice Address - Zip Code: | 80011 |
Practice Address - Country: | US |
Practice Address - Phone: | 303-364-6704 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2018-04-03 |
Last Update Date: | 2018-04-03 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
101Y00000X, 101YM0800X | ||
CO | 101YM0800X, 103K00000X, 103TC1900X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No | 101Y00000X | Behavioral Health & Social Service Providers | Counselor | |
No | 103K00000X | Behavioral Health & Social Service Providers | Behavior Analyst | |
No | 103TC1900X | Behavioral Health & Social Service Providers | Psychologist | Counseling |