Provider Demographics
NPI:1316586738
Name:MASDEN, O'MEGA
Entity Type:Individual
Prefix:
First Name:O'MEGA
Middle Name:
Last Name:MASDEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3216 BALLARD LN
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-7200
Mailing Address - Country:US
Mailing Address - Phone:812-590-2157
Mailing Address - Fax:812-645-3936
Practice Address - Street 1:3216 BALLARD LN
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-7200
Practice Address - Country:US
Practice Address - Phone:812-590-2157
Practice Address - Fax:812-645-3936
Is Sole Proprietor?:No
Enumeration Date:2020-01-02
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1975786106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician