Healthcare Provider Details

I. General information

NPI: 1346292885
Provider Name (Legal Business Name): PATRICK JOHN OBRIEN LCSW CAP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 10/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

551 NATIONAL HEALTH CARE DR
DAYTONA BEACH FL
32114-1495
US

IV. Provider business mailing address

PO BOX 730726
ORMOND BEACH FL
32173-0726
US

V. Phone/Fax

Practice location:
  • Phone: 386-323-7500
  • Fax:
Mailing address:
  • Phone: 386-492-2845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number4031CAP
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW3051
License Number StateHI
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5815
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number41718
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: