Provider Demographics
NPI:1952378390
Name:O'BRIEN, MAUREEN
Entity Type:Individual
Prefix:
First Name:MAUREEN
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:PO BOX 387
Mailing Address - Street 2:43 MALL
Mailing Address - City:WEST SAND LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12196-0387
Mailing Address - Country:US
Mailing Address - Phone:518-283-7374
Mailing Address - Fax:
Practice Address - Street 1:15 RIDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:WYNANTSKILL
Practice Address - State:NY
Practice Address - Zip Code:12198-2824
Practice Address - Country:US
Practice Address - Phone:518-674-1744
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0138581225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02209176Medicaid
NYRA5452Medicare ID - Type Unspecified
NYP26609Medicare UPIN