1093996985 NPI number — NEUROPSYCHOLOGY CLINIC

Table of content: (NPI 1093996985)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093996985 NPI number — NEUROPSYCHOLOGY CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEUROPSYCHOLOGY CLINIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093996985
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/05/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2804 20TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTHPORT
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35476-3835
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-333-1404
Provider Business Mailing Address Fax Number:
205-333-1516

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2804 20TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTHPORT
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35476-3835
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-333-1404
Provider Business Practice Location Address Fax Number:
205-333-1516
Provider Enumeration Date:
11/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PROHASKA
Authorized Official First Name:
MARK
Authorized Official Middle Name:
L
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
205-344-6169

Provider Taxonomy Codes

  • Taxonomy code: 103G00000X , with the licence number:  816 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 51504930 . This is a "BLUE CROSS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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