Provider Demographics
NPI:1730465675
Name:OGLESBY, KEITH DERELL (BS,CAC)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:DERELL
Last Name:OGLESBY
Suffix:
Gender:M
Credentials:BS,CAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 WOODRUFF RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-3429
Mailing Address - Country:US
Mailing Address - Phone:864-286-1500
Mailing Address - Fax:864-234-8255
Practice Address - Street 1:355 WOODRUFF RD
Practice Address - Street 2:SUITE 104
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-3429
Practice Address - Country:US
Practice Address - Phone:864-286-1500
Practice Address - Fax:864-234-8255
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-24
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health