Provider Demographics
NPI:1821052788
Name:OGLESBY, MARY JANE (LMHC)
Entity Type:Individual
Prefix:
First Name:MARY JANE
Middle Name:
Last Name:OGLESBY
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1559
Mailing Address - Street 2:
Mailing Address - City:BARTOW
Mailing Address - State:FL
Mailing Address - Zip Code:33831-1559
Mailing Address - Country:US
Mailing Address - Phone:863-519-0575
Mailing Address - Fax:863-582-9251
Practice Address - Street 1:715 N LAKE AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-1908
Practice Address - Country:US
Practice Address - Phone:863-413-2566
Practice Address - Fax:863-582-9251
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
FLMH7721101YM0800X
FLCAP 3106101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL767270500Medicaid