Healthcare Provider Details

I. General information

NPI: 1417267675
Provider Name (Legal Business Name): ELLEN ROSE OBRIEN LMT, CLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2010
Last Update Date: 01/31/2023
Certification Date: 01/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 SALM DR
NORTH LIBERTY IA
52317-4889
US

IV. Provider business mailing address

1130 SALM DR
NORTH LIBERTY IA
52317-4889
US

V. Phone/Fax

Practice location:
  • Phone: 319-325-5091
  • Fax:
Mailing address:
  • Phone: 319-325-5091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number16467
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number332736
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: