Healthcare Provider Details

I. General information

NPI: 1912733676
Provider Name (Legal Business Name): OBRIEN DENNIS INITIATIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2024
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 S 15TH AVE # 2
MOUNT VERNON NY
10550-2814
US

IV. Provider business mailing address

36 S 15TH AVE # 2
MOUNT VERNON NY
10550-2814
US

V. Phone/Fax

Practice location:
  • Phone: 718-869-1862
  • Fax:
Mailing address:
  • Phone: 718-869-1862
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MR. DENNIS O'BRIEN TYSON
Title or Position: PRESIDENT/CEO
Credential: MPA
Phone: 718-869-1862