MEDICARE: STACEY O'BRIEN LISW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	I-0004534	OH

General Provider Information

NPI Number	:	1114059508
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACEY O'BRIEN LISW

Provider Business Mailing Address
First Line	:	7990 W RIVER DR
Second Line	:
City	:	NOVELTY
State	:	OH
Zip	:	44072-9733
Country	:	US
Telephone Number	:	440-669-4870
Fax Number	:

Provider Business Practice Location Address
First Line	:	35010 CHARDON RD
Second Line	:	SUITE 101
City	:	WILLOUGHBY
State	:	OH
Zip	:	44094-9010
Country	:	US
Telephone Number	:	440-669-4870
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/12/2007
Last Update Date	:	07/08/2007

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Directions to “ STACEY O'BRIEN LISW” Practice Location

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