Healthcare Provider Details

I. General information

NPI: 1003852229
Provider Name (Legal Business Name): CAROL ANN OBRIEN MSW LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 01/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 12TH AVE S
BUFFALO MN
55313-2321
US

IV. Provider business mailing address

1321 13TH ST N
ST CLOUD MN
56303-2614
US

V. Phone/Fax

Practice location:
  • Phone: 763-682-4400
  • Fax: 763-682-1353
Mailing address:
  • Phone: 320-252-5010
  • Fax: 320-203-1855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number5992
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: