1083166458 NPI number — MISS MOLLY LEIGH DIETZLER O'BRIEN LICSW

Table of content: MISS MOLLY LEIGH DIETZLER O'BRIEN LICSW (NPI 1083166458)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083166458 NPI number — MISS MOLLY LEIGH DIETZLER O'BRIEN LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
O'BRIEN
Provider First Name:
MOLLY
Provider Middle Name:
LEIGH DIETZLER
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083166458
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/01/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1045 WARWICK AVE
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
WARWICK
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02888-3665
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-406-1205
Provider Business Mailing Address Fax Number:
401-270-0660

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1045 WARWICK AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
WARWICK
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02888-3665
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-406-1205
Provider Business Practice Location Address Fax Number:
401-270-0660
Provider Enumeration Date:
11/01/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  ISW02668 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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