Healthcare Provider Details

I. General information

NPI: 1417225566
Provider Name (Legal Business Name): THOMAS MICHAEL OBRIEN LPC, LADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2011
Last Update Date: 12/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

883 PADDOCK AVE
MERIDEN CT
06450-7044
US

IV. Provider business mailing address

883 PADDOCK AVE
MERIDEN CT
06450-7044
US

V. Phone/Fax

Practice location:
  • Phone: 203-630-5382
  • Fax:
Mailing address:
  • Phone: 203-630-5382
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number000242
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number000291
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: