Healthcare Provider Details

I. General information

NPI: 1356534002
Provider Name (Legal Business Name): EDYLE OBRIEN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EDYLE COPILLO CSW

II. Dates (important events)

Enumeration Date: 08/24/2007
Last Update Date: 08/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 DIANE DRIVE
EAST HAMPTON NY
11937
US

IV. Provider business mailing address

16 DIANE DRIVE
EAST HAMPTON NY
11937
US

V. Phone/Fax

Practice location:
  • Phone: 631-786-3650
  • Fax:
Mailing address:
  • Phone: 631-786-3650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number047821 1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: