Provider Demographics
NPI:1871064402
Name:O'BRIEN, STEPHANIE DANIELLA
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:DANIELLA
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 1:3006 UTOPIA PKWY
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11358-1229
Mailing Address - Country:US
Mailing Address - Phone:718-353-7612
Mailing Address - Fax:
Practice Address - Street 1:17660 UNION TPKE
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11366-1526
Practice Address - Country:US
Practice Address - Phone:718-820-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-07
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043989-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist