1487179081 NPI number — KELLI O'BRIEN BSW

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487179081 NPI number — KELLI O'BRIEN BSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
O'BRIEN
Provider First Name:
KELLI
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PERRY
Provider Other First Name:
KELLI
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1487179081
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/05/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
97 S 4TH ST STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ISHPEMING
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49849-2168
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-228-7611
Provider Business Mailing Address Fax Number:
888-977-2109

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
241 WRIGHT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARQUETTE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49855-1955
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-228-7611
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/04/2017

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: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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