Healthcare Provider Details

I. General information

NPI: 1083293898
Provider Name (Legal Business Name): NICOLE OBRIEN MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2021
Last Update Date: 04/07/2021
Certification Date: 04/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 ATLANTIC AVE
LONG BEACH NY
11561-3805
US

IV. Provider business mailing address

226 E 52ND ST
NEW YORK NY
10022-6201
US

V. Phone/Fax

Practice location:
  • Phone: 516-780-5369
  • Fax:
Mailing address:
  • Phone: 212-712-8800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: