Provider Demographics
NPI:1679824338
Name:O'BRIEN, TINA (MA CCC/SLP)
Entity type:Individual
Prefix:MRS
First Name:TINA
Middle Name:
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:MA CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11762-1622
Mailing Address - Country:US
Mailing Address - Phone:516-752-6575
Mailing Address - Fax:
Practice Address - Street 1:50 VAN COTT AVE
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-3743
Practice Address - Country:US
Practice Address - Phone:516-752-6575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-20
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01435749Medicaid