Healthcare Provider Details

I. General information

NPI: 1134809569
Provider Name (Legal Business Name): MILES OBRIEN LPC ASSOCIATE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2023
Last Update Date: 10/11/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5004 THOMPSON TER STE 112
COLLEYVILLE TX
76034-6130
US

IV. Provider business mailing address

5004 THOMPSON TER STE 112
COLLEYVILLE TX
76034-6130
US

V. Phone/Fax

Practice location:
  • Phone: 817-918-4588
  • Fax: 817-547-0749
Mailing address:
  • Phone: 817-918-4588
  • Fax: 817-547-0749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number91825
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: