Provider Demographics
NPI:1790025831
Name:O'BRIEN, LAURA COLLEEN (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:COLLEEN
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 BOOT RD
Mailing Address - Street 2:
Mailing Address - City:DOWNINGTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19335-3043
Mailing Address - Country:US
Mailing Address - Phone:484-237-5224
Mailing Address - Fax:
Practice Address - Street 1:455 BOOT RD
Practice Address - Street 2:
Practice Address - City:DOWNINGTOWN
Practice Address - State:PA
Practice Address - Zip Code:19335-3043
Practice Address - Country:US
Practice Address - Phone:484-237-5224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-27
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL006209L235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA$$$$$$$$$Medicaid