Healthcare Provider Details

I. General information

NPI: 1770716359
Provider Name (Legal Business Name): KELLY MARIE O'BRIEN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELLY MARIE CRAWFORD PH.D.

II. Dates (important events)

Enumeration Date: 08/28/2009
Last Update Date: 06/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3780 TAMPA RD SUITE #106
OLDSMAR FL
34677-3041
US

IV. Provider business mailing address

3780 TAMPA RD SUITE #106
OLDSMAR FL
34677-3041
US

V. Phone/Fax

Practice location:
  • Phone: 813-598-1652
  • Fax: 813-855-3438
Mailing address:
  • Phone: 813-598-1652
  • Fax: 813-855-3438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberFL SS 897
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: