Provider Demographics
NPI:1770716359
Name:O'BRIEN, KELLY MARIE (PHD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:MARIE
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:MARIE
Other - Last Name:CRAWFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:3780 TAMPA RD
Mailing Address - Street 2:SUITE #106
Mailing Address - City:OLDSMAR
Mailing Address - State:FL
Mailing Address - Zip Code:34677-3041
Mailing Address - Country:US
Mailing Address - Phone:813-598-1652
Mailing Address - Fax:813-855-3438
Practice Address - Street 1:3780 TAMPA RD
Practice Address - Street 2:SUITE #106
Practice Address - City:OLDSMAR
Practice Address - State:FL
Practice Address - Zip Code:34677-3041
Practice Address - Country:US
Practice Address - Phone:813-598-1652
Practice Address - Fax:813-855-3438
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-28
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFL SS 897103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool