Provider Demographics
NPI:1629345038
Name:O'BRIEN, ELIZABETH GRACE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:GRACE
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:G
Other - Last Name:O'BRIEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:26 BAUERS COVE
Mailing Address - Street 2:
Mailing Address - City:SPENCERPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14559
Mailing Address - Country:US
Mailing Address - Phone:585-352-4894
Mailing Address - Fax:
Practice Address - Street 1:2300 ENGLISH RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14616-1682
Practice Address - Country:US
Practice Address - Phone:585-966-4669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-30
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003489-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist