Provider Demographics
NPI:1942362405
Name:OLDENBURG, ROSS (MA)
Entity Type:Individual
Prefix:MR
First Name:ROSS
Middle Name:
Last Name:OLDENBURG
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:655 E CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:GLADWIN
Mailing Address - State:MI
Mailing Address - Zip Code:48624-2215
Mailing Address - Country:US
Mailing Address - Phone:989-426-9295
Mailing Address - Fax:989-426-2251
Practice Address - Street 1:655 E CEDAR AVE
Practice Address - Street 2:
Practice Address - City:GLADWIN
Practice Address - State:MI
Practice Address - Zip Code:48624-2215
Practice Address - Country:US
Practice Address - Phone:989-426-9295
Practice Address - Fax:989-426-2251
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006898103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical