Provider Demographics
NPI:1558370700
Name:OGBURN, LEIA A (LCSW)
Entity Type:Individual
Prefix:
First Name:LEIA
Middle Name:A
Last Name:OGBURN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24851 SPRING CREEK RD
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61571-9659
Mailing Address - Country:US
Mailing Address - Phone:309-219-5217
Mailing Address - Fax:
Practice Address - Street 1:4719 N SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5925
Practice Address - Country:US
Practice Address - Phone:309-682-3915
Practice Address - Fax:309-679-0703
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0087531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical