Provider Demographics
NPI:1083612865
Name:NOLL PSYCHOLOGICAL GROUP, INC
Entity Type:Organization
Organization Name:NOLL PSYCHOLOGICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:NOLL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:816-835-9882
Mailing Address - Street 1:15515 N MOUNT OLIVET RD
Mailing Address - Street 2:
Mailing Address - City:SMITHVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64089-9076
Mailing Address - Country:US
Mailing Address - Phone:816-835-9882
Mailing Address - Fax:
Practice Address - Street 1:15515 N MOUNT OLIVET RD
Practice Address - Street 2:
Practice Address - City:SMITHVILLE
Practice Address - State:MO
Practice Address - Zip Code:64089-9076
Practice Address - Country:US
Practice Address - Phone:816-835-9882
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOPYR0288103G00000X, 103TC0700X
MOPY01864103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP780000Medicare ID - Type Unspecified