Healthcare Provider Details

I. General information

NPI: 1013224484
Provider Name (Legal Business Name): MARTIN JOSEPH OBRIEN MARTIN OBRIEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MARTIN OBRIEN LADC

II. Dates (important events)

Enumeration Date: 09/08/2010
Last Update Date: 09/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 MIDDLE ST
LEWISTON ME
04240-7037
US

IV. Provider business mailing address

105 MIDDLE ST
LEWISTON ME
04240-7037
US

V. Phone/Fax

Practice location:
  • Phone: 207-212-9258
  • Fax:
Mailing address:
  • Phone: 207-212-9258
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLC4222
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: