Provider Demographics
NPI:1154401214
Name:O'BRIEN, THERESA A
Entity type:Individual
Prefix:MS
First Name:THERESA
Middle Name:A
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 1:1 N WILLARD ST
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-3651
Mailing Address - Country:US
Mailing Address - Phone:928-634-2231
Mailing Address - Fax:928-634-2874
Practice Address - Street 1:1 N WILLARD ST
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-3651
Practice Address - Country:US
Practice Address - Phone:928-634-2231
Practice Address - Fax:928-634-2874
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSW10184101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ615164Medicaid