Healthcare Provider Details

I. General information

NPI: 1790794139
Provider Name (Legal Business Name): DAVID O'BRIEN LADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 03/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 LEDGEHILL RD
BENNINGTON VT
05201-2273
US

IV. Provider business mailing address

PO BOX 588
BENNINGTON VT
05201-0588
US

V. Phone/Fax

Practice location:
  • Phone: 802-442-5491
  • Fax: 802-442-4910
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number000179
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number000179
License Number StateVT
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number000179
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: