Provider Demographics
NPI:1760716781
Name:OBRIEN, HENRY JEROME (EDS)
Entity Type:Individual
Prefix:MR
First Name:HENRY
Middle Name:JEROME
Last Name:OBRIEN
Suffix:
Gender:M
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7468 HUNTERS GREENE CIR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33810-5212
Mailing Address - Country:US
Mailing Address - Phone:863-816-7116
Mailing Address - Fax:
Practice Address - Street 1:7468 HUNTERS GREENE CIR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33810-5212
Practice Address - Country:US
Practice Address - Phone:863-816-7116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-23
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS884103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool