=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225506504
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EAMON JOSEPH O'HARA RADT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2018
-----------------------------------------------------
Last Update Date | 11/05/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1323 NEWBURY RD STE 204
-----------------------------------------------------
City | NEWBURY PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91320-3687
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-739-8345
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1323 NEWBURY RD STE 204
-----------------------------------------------------
City | NEWBURY PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91320-3687
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-739-8345
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | R1328161118
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------