Provider Demographics
NPI:1275694309
Name:OBRIEN, KIMBERLY (PHD, LICSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:OBRIEN
Suffix:
Gender:F
Credentials:PHD, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 RED GATE RD
Mailing Address - Street 2:
Mailing Address - City:WALPOLE
Mailing Address - State:MA
Mailing Address - Zip Code:02081-3785
Mailing Address - Country:US
Mailing Address - Phone:781-696-6779
Mailing Address - Fax:
Practice Address - Street 1:12 RED GATE RD
Practice Address - Street 2:
Practice Address - City:WALPOLE
Practice Address - State:MA
Practice Address - Zip Code:02081-3785
Practice Address - Country:US
Practice Address - Phone:781-696-6779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1144031041C0700X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA042611055OtherTAX ID
MA703136OtherTUFTS
MAM18633OtherBCBC
MANP01332OtherBMC
MA1004745OtherNHP
MA1303287OtherMBHP
MA1303287Medicaid
MANP01332OtherBMC