Provider Demographics
NPI:1346072279
Name:OGBASELASE, FREWINE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:FREWINE
Middle Name:
Last Name:OGBASELASE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2706 S 73RD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19153-2311
Mailing Address - Country:US
Mailing Address - Phone:267-972-3210
Mailing Address - Fax:
Practice Address - Street 1:701 E CATHEDRAL RD STE 45
Practice Address - Street 2:421
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128
Practice Address - Country:US
Practice Address - Phone:267-972-3210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-19
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL017704235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist