Provider Demographics
NPI:1700427432
Name:BOODAH, INC
Entity Type:Organization
Organization Name:BOODAH, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:LONG
Authorized Official - Last Name:GALLICCHIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-593-2560
Mailing Address - Street 1:2 BUSHWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:LADERA RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:92694-0513
Mailing Address - Country:US
Mailing Address - Phone:800-593-2560
Mailing Address - Fax:800-593-2560
Practice Address - Street 1:27281 LAS RAMBLAS STE 200
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-8303
Practice Address - Country:US
Practice Address - Phone:800-593-2560
Practice Address - Fax:800-593-2560
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOODAH INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-10-03
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty