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
1	103T00000X	Psychologist

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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Directions to “BOODAH, INC ” Practice Location

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