=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487703989
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEVIN MICHAEL O'LEARY PSY.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2550 DENALI ST STE 1610
-----------------------------------------------------
City | ANCHORAGE
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99503-2753
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-646-9950
-----------------------------------------------------
Fax | 907-646-9831
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2550 DENALI ST STE 1610
-----------------------------------------------------
City | ANCHORAGE
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99503-2753
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-646-9950
-----------------------------------------------------
Fax | 907-646-9831
-----------------------------------------------------
=====================================================
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 | 512
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------