Provider Demographics
NPI:1619081841
Name:OBRIEN, CAROL MARIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:MARIE
Last Name:OBRIEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11115 66TH TER
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33772-6241
Mailing Address - Country:US
Mailing Address - Phone:727-631-2679
Mailing Address - Fax:
Practice Address - Street 1:10823 SEMINOLE BLVD
Practice Address - Street 2:SUITE 3A
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33778-3347
Practice Address - Country:US
Practice Address - Phone:727-631-2679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5151103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54233Medicare ID - Type Unspecified