Healthcare Provider Details

I. General information

NPI: 1932853777
Provider Name (Legal Business Name): MEGAN THOMAS O'BRIEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2022
Last Update Date: 02/10/2022
Certification Date: 02/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 GREEN BAY RD
KENILWORTH IL
60043-1001
US

IV. Provider business mailing address

441 E ERIE ST APT 2412
CHICAGO IL
60611-7125
US

V. Phone/Fax

Practice location:
  • Phone: 847-919-9096
  • Fax:
Mailing address:
  • Phone: 269-823-2268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: