MEDICARE: AMY O'HERRON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TS0200X	School Psychologist	375349	NM

General Provider Information

NPI Number	:	1194508887
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY O'HERRON

Provider Business Mailing Address
First Line	:	10601 RESEARCH RD SE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87123-3492
Country	:	US
Telephone Number	:	505-344-5470
Fax Number	:

Provider Business Practice Location Address
First Line	:	10601 RESEARCH RD SE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87123-3492
Country	:	US
Telephone Number	:	505-344-5470
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/16/2023
Last Update Date	:	08/16/2023

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