Healthcare Provider Details

I. General information

NPI: 1114793627
Provider Name (Legal Business Name): GREGORY OBRIEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2023
Last Update Date: 11/27/2023
Certification Date: 11/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10221 W LINCOLN HWY
FRANKFORT IL
60423-1279
US

IV. Provider business mailing address

750 WILDWOOD DR
NEW LENOX IL
60451-3358
US

V. Phone/Fax

Practice location:
  • Phone: 815-806-7560
  • Fax:
Mailing address:
  • Phone: 708-297-4182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: