Provider Demographics
NPI:1346410586
Name:O'BRIEN, MARY ELLEN (SLP-A)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:SLP-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11707 LIPSEY RD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-3619
Mailing Address - Country:US
Mailing Address - Phone:813-961-0762
Mailing Address - Fax:
Practice Address - Street 1:3117 LITHIA PINECREST RD
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33596-5632
Practice Address - Country:US
Practice Address - Phone:813-662-1106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-04
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSI647222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist