Provider Demographics
NPI:1770132706
Name:O'BRIEN, CAILTIN MARIE
Entity type:Individual
Prefix:
First Name:CAILTIN
Middle Name:MARIE
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 1:18 LILLIAN WAY
Mailing Address - Street 2:
Mailing Address - City:CARVER
Mailing Address - State:MA
Mailing Address - Zip Code:02330-1137
Mailing Address - Country:US
Mailing Address - Phone:508-322-0512
Mailing Address - Fax:
Practice Address - Street 1:110 S MADISON ST
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-2518
Practice Address - Country:US
Practice Address - Phone:508-322-0512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-11
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010021972255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2601002197OtherATHLETIC TRAINING BOC