Provider Demographics
NPI:1457579427
Name:O'BRIEN, JOHN (LICSW)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:O'BRIEN
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W 98TH ST
Mailing Address - Street 2:STE 107
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55420-4858
Mailing Address - Country:US
Mailing Address - Phone:612-968-6097
Mailing Address - Fax:
Practice Address - Street 1:200 W 98TH ST
Practice Address - Street 2:STE 107
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420-4858
Practice Address - Country:US
Practice Address - Phone:612-968-6097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN143131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN689136500Medicaid
MN205436246OtherEID