=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033802855
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OMATA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/29/2023
-----------------------------------------------------
Last Update Date | 05/29/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4530 S ORANGE BLOSSOM TRL # 924
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32839-1704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 959-265-2947
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 FELLOWS RD APT 47
-----------------------------------------------------
City | OAKDALE
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06370-1624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MORGAN A AJELLO
-----------------------------------------------------
Credential | LMHC
-----------------------------------------------------
Telephone | 860-334-5900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------