MEDICARE: MRS. AMY JO O'DELL

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1891227401
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AMY JO O'DELL

Provider Business Mailing Address
First Line	:	1153 LAS CRUCES DR
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454-5700
Country	:	US
Telephone Number	:	757-513-8600
Fax Number	:

Provider Business Practice Location Address
First Line	:	1153 LAS CRUCES DR
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454-5700
Country	:	US
Telephone Number	:	757-513-8600
Fax Number	:

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

Provider Enumeration Date	:	04/02/2017
Last Update Date	:	04/02/2017

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