Provider Demographics
NPI:1407129703
Name:OBRIEN, KELLY (LCSW, MCAP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:OBRIEN
Suffix:
Gender:F
Credentials:LCSW, MCAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6472 BAY OAKS DR
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32583-7415
Mailing Address - Country:US
Mailing Address - Phone:850-733-6671
Mailing Address - Fax:
Practice Address - Street 1:7552 NAVARRE PKWY UNIT 4
Practice Address - Street 2:
Practice Address - City:NAVARRE
Practice Address - State:FL
Practice Address - Zip Code:32566-7312
Practice Address - Country:US
Practice Address - Phone:850-733-6671
Practice Address - Fax:855-490-2281
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-16
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101YA0400X
NJ44SC051947001041C0700X
FLSW113751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)