Provider Demographics
NPI:1093996985
Name:NEUROPSYCHOLOGY CLINIC
Entity Type:Organization
Organization Name:NEUROPSYCHOLOGY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:L
Authorized Official - Last Name:PROHASKA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:205-344-6169
Mailing Address - Street 1:2804 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35476-3835
Mailing Address - Country:US
Mailing Address - Phone:205-333-1404
Mailing Address - Fax:205-333-1516
Practice Address - Street 1:2804 20TH AVE
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:AL
Practice Address - Zip Code:35476-3835
Practice Address - Country:US
Practice Address - Phone:205-333-1404
Practice Address - Fax:205-333-1516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-19
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL816103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51504930OtherBLUE CROSS
ALS27539Medicare UPIN
AL51504930OtherBLUE CROSS