Basic Information
| Provider Information | |||||||||
| NPI: | 1720282320 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OGDEN | ||||||||
| FirstName: | GREG | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMFT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | OGDEN | ||||||||
| OtherFirstName: | GREGORY | ||||||||
| OtherMiddleName: | DEAN | ||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMFT | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2225 N UNION ST | ||||||||
| Address2: | |||||||||
| City: | PONCA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 746011555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183085515 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2225 N UNION ST | ||||||||
| Address2: | |||||||||
| City: | PONCA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 746011555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183085515 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2007 | ||||||||
| LastUpdateDate: | 10/13/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 297 | KS | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 106H00000X | ID | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | 0357 | KS | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 100229210A | 05 | KS | MEDICAID |