Healthcare Provider Details

I. General information

NPI: 1255025979
Provider Name (Legal Business Name): KATHLEEN ANN OBRIEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2023
Last Update Date: 06/08/2023
Certification Date: 06/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 ETHAN WAY
SACRAMENTO CA
95825-2211
US

IV. Provider business mailing address

850 TOWBIN AVE
LAKEWOOD NJ
08701-5928
US

V. Phone/Fax

Practice location:
  • Phone: 833-599-2560
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: