MEDICARE: STEPHANIE OBRIEN PC

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	101YM0800X	Mental Health Counselor	5580127-6004	UT

General Provider Information

NPI Number	:	1568660108
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE OBRIEN PC

Provider Business Mailing Address
First Line	:	650 KOMAS DR STE 200
Second Line	:
City	:	SLC
State	:	UT
Zip	:	84108-1241
Country	:	US
Telephone Number	:	801-585-9097
Fax Number	:	801-581-8979

Provider Business Practice Location Address
First Line	:	650 KOMAS DR STE 200
Second Line	:
City	:	SLC
State	:	UT
Zip	:	84108-1241
Country	:	US
Telephone Number	:	801-585-9097
Fax Number	:	801-581-8979

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

Provider Enumeration Date	:	07/05/2007
Last Update Date	:	05/12/2015

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