Provider Demographics
NPI:1346312659
Name:O'BRIEN, KERRY LEE (LICSW)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:LEE
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 CHURCH ST SE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-0340
Mailing Address - Country:US
Mailing Address - Phone:612-625-8400
Mailing Address - Fax:612-625-1434
Practice Address - Street 1:410 CHURCH ST SE
Practice Address - Street 2:BOYNTON HEALTH SERVICE
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0340
Practice Address - Country:US
Practice Address - Phone:612-625-8400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN84621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical