Healthcare Provider Details

I. General information

NPI: 1457025041
Provider Name (Legal Business Name): HEIDI MARIE OBRIEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2021
Last Update Date: 08/06/2021
Certification Date: 08/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

196 E EMMITT AVE
WAVERLY OH
45690-1334
US

IV. Provider business mailing address

617 S MARKET ST APT 14
WAVERLY OH
45690-1660
US

V. Phone/Fax

Practice location:
  • Phone: 740-912-9499
  • Fax:
Mailing address:
  • Phone: 740-222-3645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN.149402.MEDS-IV
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: