Provider Demographics
NPI:1114059508
Name:O'BRIEN, STACEY (LISW)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:GRINNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7990 W RIVER DR
Mailing Address - Street 2:
Mailing Address - City:NOVELTY
Mailing Address - State:OH
Mailing Address - Zip Code:44072-9733
Mailing Address - Country:US
Mailing Address - Phone:440-669-4870
Mailing Address - Fax:
Practice Address - Street 1:35010 CHARDON RD
Practice Address - Street 2:SUITE 101
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-9010
Practice Address - Country:US
Practice Address - Phone:440-669-4870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI-00045341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical