Provider Demographics
NPI:1366775025
Name:OGLESBY, ANGELA K (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:K
Last Name:OGLESBY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1489 HAMBURG RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:IL
Mailing Address - Zip Code:62977-1272
Mailing Address - Country:US
Mailing Address - Phone:618-242-8887
Mailing Address - Fax:618-242-2551
Practice Address - Street 1:4121 VETERANS MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6262
Practice Address - Country:US
Practice Address - Phone:618-242-3778
Practice Address - Fax:618-242-2551
Is Sole Proprietor?:No
Enumeration Date:2009-09-14
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056008796225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL056008796OtherSTATE LICENSE