Provider Demographics
NPI:1831460799
Name:OBRIEN, TERI L (PTA)
Entity Type:Individual
Prefix:
First Name:TERI
Middle Name:L
Last Name:OBRIEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 SE 12TH ST
Mailing Address - Street 2:#203
Mailing Address - City:DANIA
Mailing Address - State:FL
Mailing Address - Zip Code:33004-5360
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4200 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-7353
Practice Address - Country:US
Practice Address - Phone:954-981-6300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-24
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20311310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility