Provider Demographics
NPI:1568830511
Name:O'BRIEN, MICAH BENJAMIN (PTA)
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:BENJAMIN
Last Name:O'BRIEN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25829 185TH PL SE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98042-8446
Mailing Address - Country:US
Mailing Address - Phone:206-354-7103
Mailing Address - Fax:
Practice Address - Street 1:4560 SE INTERNATIONAL WAY
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-4628
Practice Address - Country:US
Practice Address - Phone:971-206-5202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-08
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP160560447225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant