Healthcare Provider Details

I. General information

NPI: 1700020534
Provider Name (Legal Business Name): JUNE OBRIEN CDP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2009
Last Update Date: 04/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 SE PAULCYN LN
SHELTON WA
98584-9378
US

IV. Provider business mailing address

81 SE PAULCYN LANE
SHELTON WA
98584-1234
US

V. Phone/Fax

Practice location:
  • Phone: 360-427-9613
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP00000135
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: