Provider Demographics
NPI:1417267675
Name:OBRIEN, ELLEN ROSE (LMT, CLC)
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:ROSE
Last Name:OBRIEN
Suffix:
Gender:F
Credentials:LMT, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 SALM DR
Mailing Address - Street 2:
Mailing Address - City:NORTH LIBERTY
Mailing Address - State:IA
Mailing Address - Zip Code:52317-4889
Mailing Address - Country:US
Mailing Address - Phone:319-325-5091
Mailing Address - Fax:
Practice Address - Street 1:1130 SALM DR
Practice Address - Street 2:
Practice Address - City:NORTH LIBERTY
Practice Address - State:IA
Practice Address - Zip Code:52317-4889
Practice Address - Country:US
Practice Address - Phone:319-325-5091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-20
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16467225700000X
IA332736163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist