Healthcare Provider Details

I. General information

NPI: 1760716781
Provider Name (Legal Business Name): HENRY JEROME OBRIEN ED.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2009
Last Update Date: 09/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7468 HUNTERS GREENE CIR
LAKELAND FL
33810-5212
US

IV. Provider business mailing address

7468 HUNTERS GREENE CIR
LAKELAND FL
33810-5212
US

V. Phone/Fax

Practice location:
  • Phone: 863-816-7116
  • Fax:
Mailing address:
  • Phone: 863-816-7116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberSS884
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: