Provider Demographics
NPI:1790993517
Name:OGLESBY, MARY KATHERINE (MCD, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:KATHERINE
Last Name:OGLESBY
Suffix:
Gender:F
Credentials:MCD, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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Mailing Address - Street 1:1079 COUNTY ROAD 176
Mailing Address - Street 2:
Mailing Address - City:GUNTOWN
Mailing Address - State:MS
Mailing Address - Zip Code:38849-8521
Mailing Address - Country:US
Mailing Address - Phone:662-231-3179
Mailing Address - Fax:662-869-3618
Practice Address - Street 1:1079 COUNTY ROAD 176
Practice Address - Street 2:
Practice Address - City:GUNTOWN
Practice Address - State:MS
Practice Address - Zip Code:38849-8521
Practice Address - Country:US
Practice Address - Phone:662-231-3179
Practice Address - Fax:662-869-3618
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2818235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03186379Medicaid