=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902284458
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARYELLEN O'BRIEN LMHC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2015
-----------------------------------------------------
Last Update Date | 05/19/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 630 PLANTATION ST
-----------------------------------------------------
City | WORCESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01605-2038
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-853-2854
-----------------------------------------------------
Fax | 508-853-4354
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 630 PLANTATION ST WOT 2ND FL, SUITE C203
-----------------------------------------------------
City | WORCESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01605-2038
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-368-5532
-----------------------------------------------------
Fax | 508-853-4354
-----------------------------------------------------
=====================================================
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 | 1196
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 611
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------