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NPI Code Detail

MEDICARE: BOODAH, INC

MEDICARE: BOODAH, INC
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
1103T00000XPsychologist

General Provider Information

NPI Number : 1700427432
Entity Type Code : Organization
Provider Name (Legal Business Name) : BOODAH, INC
Provider Business Mailing Address
First Line : 2 BUSHWOOD CIR
Second Line :
City : LADERA RANCH
State : CA
Zip : 92694-0513
Country : US
Telephone Number : 800-593-2560
Fax Number : 800-593-2560
Provider Business Practice Location Address
First Line : 27281 LAS RAMBLAS STE 200
Second Line :
City : MISSION VIEJO
State : CA
Zip : 92691-8303
Country : US
Telephone Number : 800-593-2560
Fax Number : 800-593-2560
Authorized Official
Title or Position : OWNER/PROVIDER
Name : COLLEEN LONG GALLICCHIO
Credential :
Telephone Number : 800-593-2560
Provider Enumeration Date : 10/03/2019
Last Update Date : 10/03/2019

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