Provider Demographics
NPI:1659789089
Name:O'BRIEN, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
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 1:1039 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-3623
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1039 FOREST AVE
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-3623
Practice Address - Country:US
Practice Address - Phone:815-326-0488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-29
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist