MEDICARE: CRYSTAL O'MARA BCABA

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	106E00000X	Assistant Behavior Analyst

General Provider Information

NPI Number	:	1881130052
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL O'MARA BCABA

Provider Business Mailing Address
First Line	:	3904 OLEANDER DR
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28403-6717
Country	:	US
Telephone Number	:	910-313-3232
Fax Number	:	910-313-6598

Provider Business Practice Location Address
First Line	:	3904 OLEANDER DR
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28403-6717
Country	:	US
Telephone Number	:	910-313-3232
Fax Number	:	910-313-6598

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

Provider Enumeration Date	:	01/12/2017
Last Update Date	:	01/12/2017

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