Provider Demographics
NPI:1154549384
Name:O BRIEN, DENISE M (MSRDCD)
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:M
Last Name:O BRIEN
Suffix:
Gender:F
Credentials:MSRDCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6605 HILLWOOD CT
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53403-9463
Mailing Address - Country:US
Mailing Address - Phone:262-553-9635
Mailing Address - Fax:
Practice Address - Street 1:1701 SHARP RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:WI
Practice Address - Zip Code:53185-5214
Practice Address - Country:US
Practice Address - Phone:262-534-7297
Practice Address - Fax:262-534-7257
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1228-029133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered