Provider Demographics
NPI:1033509492
Name:NEURO-DIAGNOSTIX
Entity Type:Organization
Organization Name:NEURO-DIAGNOSTIX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:CICETTI
Authorized Official - Suffix:
Authorized Official - Credentials:PSY, D LMHC
Authorized Official - Phone:561-734-6118
Mailing Address - Street 1:1101 N CONGRESS AVE STE 208
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33426
Mailing Address - Country:US
Mailing Address - Phone:561-734-6118
Mailing Address - Fax:
Practice Address - Street 1:555 HERITAGE DRIVE STE 110
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458
Practice Address - Country:US
Practice Address - Phone:561-734-6118
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-23
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7715291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory