Provider Demographics
NPI:1134280100
Name:O BRIEN, LISA CAMILLE (LCSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:CAMILLE
Last Name:O BRIEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7300 N PERIMETER ROAD
Mailing Address - Street 2:341 MEDICAL GROUP
Mailing Address - City:MALMSTROM
Mailing Address - State:MT
Mailing Address - Zip Code:59402
Mailing Address - Country:US
Mailing Address - Phone:406-731-4290
Mailing Address - Fax:406-731-0000
Practice Address - Street 1:7300 N PERIMETER ROAD
Practice Address - Street 2:341 MEDICAL GROUP
Practice Address - City:MALMSTROM
Practice Address - State:MT
Practice Address - Zip Code:59402
Practice Address - Country:US
Practice Address - Phone:406-731-4290
Practice Address - Fax:406-731-0000
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT7121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0503778Medicaid