=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255060018
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OHEARN PSYCHOLOGICAL SERVICES PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2022
-----------------------------------------------------
Last Update Date | 06/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 74 MEADOWBROOK RD
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14620-3030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-820-1573
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 620 PARK AVE # 113
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14607-2943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-820-1573
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. AMANDA OHEARN
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 585-820-1573
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------