Provider Demographics
NPI:1063941136
Name:O'HEARN, AYDIN
Entity type:Individual
Prefix:
First Name:AYDIN
Middle Name:
Last Name:O'HEARN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 S PARK ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:12816-1223
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24 S PARK ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:NY
Practice Address - Zip Code:12816-1223
Practice Address - Country:US
Practice Address - Phone:518-677-8527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-12
Last Update Date:2017-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP05891101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health