1437663499 NPI number — LIFESPAN NEUROPSYCHOLOGICAL SERVICES, PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437663499 NPI number — LIFESPAN NEUROPSYCHOLOGICAL SERVICES, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFESPAN NEUROPSYCHOLOGICAL SERVICES, PLLC
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:
1437663499
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/28/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
31600 TELEGRAPH RD STE 250
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BINGHAM FARMS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48025-4317
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-690-6993
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
31600 TELEGRAPH RD STE 250
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BINGHAM FARMS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48025-4317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-690-6993
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/28/2017

Additional Information

Authorized Official

Authorized Official Last Name:
ANTONUCCI
Authorized Official First Name:
AMI
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
248-690-6993

Provider Taxonomy Codes

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

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





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