Provider Demographics
NPI:1174274120
Name:STATE OF MIND NEUROPSYCHOLOGY LLC
Entity Type:Organization
Organization Name:STATE OF MIND NEUROPSYCHOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/NEUROPSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:HELENE
Authorized Official - Last Name:PUSKAR
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:724-317-1647
Mailing Address - Street 1:PO BOX 420
Mailing Address - Street 2:
Mailing Address - City:PERRYOPOLIS
Mailing Address - State:PA
Mailing Address - Zip Code:15473-0420
Mailing Address - Country:US
Mailing Address - Phone:724-317-1647
Mailing Address - Fax:
Practice Address - Street 1:2714 MEMORIAL BLVD
Practice Address - Street 2:
Practice Address - City:CONNELLSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15425-1406
Practice Address - Country:US
Practice Address - Phone:724-317-1647
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-11
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & AgingGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty