MEDICARE: HEIDI OKAMOTO B.C.B.A.

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	:	1962758318
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEIDI OKAMOTO B.C.B.A.

Provider Business Mailing Address
First Line	:	151 CALLAN AVE
Second Line	:	SUITE 204
City	:	SAN LEANDRO
State	:	CA
Zip	:	94577-4536
Country	:	US
Telephone Number	:	925-895-6961
Fax Number	:	510-357-8399

Provider Business Practice Location Address
First Line	:	151 CALLAN AVE
Second Line	:	SUITE 204
City	:	SAN LEANDRO
State	:	CA
Zip	:	94577-4536
Country	:	US
Telephone Number	:	925-895-6961
Fax Number	:	510-357-8399

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

Provider Enumeration Date	:	08/02/2012
Last Update Date	:	08/02/2012

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