=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164462883
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUZANNE M O'BRIEN PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2006
-----------------------------------------------------
Last Update Date | 11/24/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2125 S EL CAMINO REAL SUITE 104
-----------------------------------------------------
City | OCEANSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92054-6260
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-877-0175
-----------------------------------------------------
Fax | 760-967-6042
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2125 S EL CAMINO REAL SUITE 104
-----------------------------------------------------
City | OCEANSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92054-6260
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-877-0175
-----------------------------------------------------
Fax | 760-967-6042
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY20502
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------