Provider Demographics
NPI:1083043079
Name:NEUROPSYCHOLOGY SERVICES OF SOUTHWEST OHIO, LLC
Entity Type:Organization
Organization Name:NEUROPSYCHOLOGY SERVICES OF SOUTHWEST OHIO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:DONINGER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:847-421-6323
Mailing Address - Street 1:4954 WALNUT WALK
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-1936
Mailing Address - Country:US
Mailing Address - Phone:847-421-6323
Mailing Address - Fax:937-395-8139
Practice Address - Street 1:1 ELIZABETH PL
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-3445
Practice Address - Country:US
Practice Address - Phone:937-424-8306
Practice Address - Fax:937-222-7726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-11
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6061103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0094672Medicaid