Provider Demographics
NPI:1558488437
Name:O'BRIEN, JOHN BERNARD
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:BERNARD
Last Name:O'BRIEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 14TH ST
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-2506
Mailing Address - Country:US
Mailing Address - Phone:209-525-5401
Mailing Address - Fax:
Practice Address - Street 1:2516 MAESTRO WAY
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-9658
Practice Address - Country:US
Practice Address - Phone:209-505-3900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC051710318101YA0400X
CA138808106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)