MEDICARE: MRS. CARLEIGH OBRIEN LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	BBH-LCSW-LIC-22989	MT

General Provider Information

NPI Number	:	1073035069
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CARLEIGH OBRIEN LCSW

Provider Business Mailing Address
First Line	:	30 FORT MISSOULA RD STE A
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59804-7218
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	30 FORT MISSOULA RD STE A
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59804-7218
Country	:	US
Telephone Number	:	773-870-5396
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/11/2017
Last Update Date	:	07/11/2017

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