Provider Demographics
NPI:1295558187
Name:O'BRIEN, MIRANDA
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
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 1:1514 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94122-3308
Mailing Address - Country:US
Mailing Address - Phone:510-610-5623
Mailing Address - Fax:
Practice Address - Street 1:3800 COOLIDGE AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94602-3311
Practice Address - Country:US
Practice Address - Phone:510-482-2244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-07
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA127601104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker