Healthcare Provider Details

I. General information

NPI: 1275916645
Provider Name (Legal Business Name): KEVIN OBRIEN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: KEVIN OBRIEN LCSW

II. Dates (important events)

Enumeration Date: 07/03/2015
Last Update Date: 07/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 W GROCHOWIAK ST
SOUTH RIVER NJ
08882-1539
US

IV. Provider business mailing address

21 W GROCHOWIAK ST
SOUTH RIVER NJ
08882-1539
US

V. Phone/Fax

Practice location:
  • Phone: 732-257-1633
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number44SC05271000
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC05271000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: