Provider Demographics
NPI:1205083516
Name:O'BRIEN, JOHANNA LORETTA
Entity type:Individual
Prefix:MRS
First Name:JOHANNA
Middle Name:LORETTA
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:642 HACKBERRY RD
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62629-1120
Mailing Address - Country:US
Mailing Address - Phone:815-757-5067
Mailing Address - Fax:
Practice Address - Street 1:642 HACKBERRY RD
Practice Address - Street 2:
Practice Address - City:CHATHAM
Practice Address - State:IL
Practice Address - Zip Code:62629-1120
Practice Address - Country:US
Practice Address - Phone:815-757-5067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-19
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist