Provider Demographics
NPI:1255677605
Name:NEUROBEHAVIORAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:NEUROBEHAVIORAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO, NEUROPSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:B
Authorized Official - Last Name:HERTZA
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:706-823-5250
Mailing Address - Street 1:1355 INDEPENDENCE DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-1037
Mailing Address - Country:US
Mailing Address - Phone:706-823-5250
Mailing Address - Fax:706-823-5266
Practice Address - Street 1:639 13TH ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-1007
Practice Address - Country:US
Practice Address - Phone:706-823-5250
Practice Address - Fax:706-823-5266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-12
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103G00000X
GAPSY003527103G00000X
GAPSY003355103TC0700X
GAPSY003548103TC2200X
GAPSY003309103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202G702895Medicare PIN
GA202I681023OtherMEDICARE PTAN
GA202I680756OtherMEDICARE PTAN
GA202I689195OtherMEDICARE PTAN