Basic Information
Provider Information | |||||||||
NPI: | 1518509470 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FARRELL | ||||||||
FirstName: | OLIVIA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MA, BCBA, COBA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 475 PARK BLVD | ||||||||
Address2: |   | ||||||||
City: | WORTHINGTON | ||||||||
State: | OH | ||||||||
PostalCode: | 430853789 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6145708092 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3070 RIVERSIDE DR STE 200 | ||||||||
Address2: |   | ||||||||
City: | COLUMBUS | ||||||||
State: | OH | ||||||||
PostalCode: | 432212547 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6146155145 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/11/2019 | ||||||||
LastUpdateDate: | 10/11/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-18-31060 | OH | Y |   | Behavioral Health & Social Service Providers | Behavioral Analyst |   |
No ID Information.