Provider Demographics
NPI:1831919331
Name:LEBOGANG, SEGOLAME
Entity type:Individual
Prefix:
First Name:SEGOLAME
Middle Name:
Last Name:LEBOGANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:ELDORADO
Mailing Address - State:IL
Mailing Address - Zip Code:62930-1722
Mailing Address - Country:US
Mailing Address - Phone:618-252-9036
Mailing Address - Fax:618-216-9993
Practice Address - Street 1:301 S WALL ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-3240
Practice Address - Country:US
Practice Address - Phone:618-252-9036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-10
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health