Provider Demographics
NPI:1801378575
Name:O'BRIEN, KIMBRA L (LCAC)
Entity Type:Individual
Prefix:
First Name:KIMBRA
Middle Name:L
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:LCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1417 N ANTHONY BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5252
Mailing Address - Country:US
Mailing Address - Phone:260-424-5814
Mailing Address - Fax:260-424-6423
Practice Address - Street 1:1417 N ANTHONY BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5252
Practice Address - Country:US
Practice Address - Phone:260-424-5814
Practice Address - Fax:260-424-6423
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN870001674A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)