MEDICARE: JUSTINE BEACHLEY O'MEARA MS, BCBA, LBA

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	103K00000X	Behavior Analyst
2	103K00000X	Behavior Analyst	1-18-29528

General Provider Information

NPI Number	:	1710450515
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUSTINE BEACHLEY O'MEARA MS, BCBA, LBA

Provider Business Mailing Address
First Line	:	111 E OSTEND ST
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21230-4309
Country	:	US
Telephone Number	:	240-425-7239
Fax Number	:

Provider Business Practice Location Address
First Line	:	2617 CHRISTIAN ST UNIT A
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19146-2315
Country	:	US
Telephone Number	:	240-425-7239
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/04/2019
Last Update Date	:	03/23/2023

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