Healthcare Provider Details

I. General information

NPI: 1588843296
Provider Name (Legal Business Name): MICHAEL A. O'BRYANT LADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2007
Last Update Date: 10/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 HANOVER ST
MANCHESTER NH
03104-6115
US

IV. Provider business mailing address

PO BOX 6597
PENACOOK NH
03303-6597
US

V. Phone/Fax

Practice location:
  • Phone: 603-622-3020
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number620
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: