Healthcare Provider Details

I. General information

NPI: 1710105713
Provider Name (Legal Business Name): TERRANCE EDWARD OBRIEN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 NORTH BURDICK ST. SUITE 109
EAST SYRACUSE NY
13057
US

IV. Provider business mailing address

7239 ROUMARE ROAD
EAST SYRACUSE NY
13057
US

V. Phone/Fax

Practice location:
  • Phone: 315-656-2174
  • Fax:
Mailing address:
  • Phone: 315-656-2174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number000475-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: