Provider Demographics
NPI:1780448183
Name:KELLY OBRIEN LICENSED CLINICAL SOCIAL WORKER
Entity type:Organization
Organization Name:KELLY OBRIEN LICENSED CLINICAL SOCIAL WORKER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MBR
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:THERESA
Authorized Official - Last Name:O'BRIEN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:315-325-8619
Mailing Address - Street 1:365 SUMMERHAVEN DR N
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-3130
Mailing Address - Country:US
Mailing Address - Phone:315-325-8619
Mailing Address - Fax:
Practice Address - Street 1:365 SUMMERHAVEN DR N
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-3130
Practice Address - Country:US
Practice Address - Phone:315-325-8619
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-07
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty