=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740869536
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CASEY NICOLE O'BRIEN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2021
-----------------------------------------------------
Last Update Date | 04/07/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1353 N COURTENAY PKWY STE L
-----------------------------------------------------
City | MERRITT ISLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32953-4463
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-978-5122
-----------------------------------------------------
Fax | 321-978-5127
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5150 GARFIELD ST
-----------------------------------------------------
City | COCOA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32927-3134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-745-7920
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | ISW14944
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | ISW14944
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------