Healthcare Provider Details

I. General information

NPI: 1740716760
Provider Name (Legal Business Name): ELIZABETH OBRIEN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 09/11/2025
Certification Date: 05/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 MAIN RD
AQUEBOGUE NY
11931
US

IV. Provider business mailing address

200 CRANFORD BLVD
MASTIC NY
11950-1329
US

V. Phone/Fax

Practice location:
  • Phone: 631-903-4333
  • Fax:
Mailing address:
  • Phone: 631-903-4333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number098825
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: