Healthcare Provider Details

I. General information

NPI: 1316226863
Provider Name (Legal Business Name): KEVIN JAMES OBRIEN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2011
Last Update Date: 08/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2504 CAMIO ENTRADA
SANTA FE NM
87507-5456
US

IV. Provider business mailing address

2504 CAMINO ENTRADA SANTA FE FAMILY WELLNESS CENTER
SANTA FE NM
87507
US

V. Phone/Fax

Practice location:
  • Phone: 505-471-5006
  • Fax:
Mailing address:
  • Phone: 505-471-5006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-07396
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: