Organization
EBB TIDE THERAPY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. SHANNON GAE O'BRIEN LCSW, CSAC, CTS (THERAPIST)
(414) 372-7212
Entity
Organization
Contact information
Practice address
2821 N 4TH ST STE 209, MILWAUKEE, WI 53212-2367
(414) 372-7212
(414) 372-7213
Mailing address
2821 N 4TH ST STE 209, MILWAUKEE, WI 53212-2367
(414) 372-7212
(414) 372-7213
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
1971-132
—
1041C0700X
Clinical Social Worker
Primary
7197-123
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1366529182
—
WI
Enumeration date
03/09/2012
Last updated
07/05/2012
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