Healthcare Provider Details

I. General information

NPI: 1215978895
Provider Name (Legal Business Name): PAUL R. O'BRIEN EDD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 03/07/2021
Certification Date: 03/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 CITY HALL MALL
MEDFORD MA
02155-4754
US

IV. Provider business mailing address

26 CITY HALL MALL
MEDFORD MA
02155-4754
US

V. Phone/Fax

Practice location:
  • Phone: 781-306-5100
  • Fax:
Mailing address:
  • Phone: 781-306-5100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6024
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: