Provider Demographics
NPI:1790184182
Name:OGBURN COUNSELING SERVICES, LLC
Entity Type:Organization
Organization Name:OGBURN COUNSELING SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:LEIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:OGBURN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:309-682-3915
Mailing Address - Street 1:5113 N EXECUTIVE DR STE 101
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-4884
Mailing Address - Country:US
Mailing Address - Phone:309-682-3915
Mailing Address - Fax:309-679-0703
Practice Address - Street 1:5113 N EXECUTIVE DR STE 101
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-4884
Practice Address - Country:US
Practice Address - Phone:309-682-3915
Practice Address - Fax:309-679-0703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-21
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0087531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty