Healthcare Provider Details

I. General information

NPI: 1801519210
Provider Name (Legal Business Name): KEVIN O'BRIEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2022
Last Update Date: 06/14/2023
Certification Date: 06/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 FULLER AVE NE
GRAND RAPIDS MI
49503-1918
US

IV. Provider business mailing address

790 FULLER AVE NE
GRAND RAPIDS MI
49503-1918
US

V. Phone/Fax

Practice location:
  • Phone: 616-336-3909
  • Fax:
Mailing address:
  • Phone: 989-464-4069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: