=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831440130
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TIM OBRIEN LPC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2012
-----------------------------------------------------
Last Update Date | 09/26/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1506 SE CUTTER LN
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98661-8084
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-853-6843
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 405 W ARLINGTON ST
-----------------------------------------------------
City | GLADSTONE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97027-2308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-853-6843
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | TIM OBRIEN
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 503-853-6843
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | C1454
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------