Provider Demographics
NPI:1861890758
Name:O'BRIEN, SUE ANN
Entity type:Individual
Prefix:
First Name:SUE
Middle Name:ANN
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:754 JUNIPER ST NE APT 2
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308-1955
Mailing Address - Country:US
Mailing Address - Phone:602-525-1092
Mailing Address - Fax:
Practice Address - Street 1:754 JUNIPER ST NE APT 2
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-1955
Practice Address - Country:US
Practice Address - Phone:602-525-1092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-09
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC1886101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZPENDINGMedicaid