Provider Demographics
NPI:1326451055
Name:NEUROBEHAVIORAL DIAGNOSTICS LLC
Entity Type:Organization
Organization Name:NEUROBEHAVIORAL DIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:KRUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-434-4838
Mailing Address - Street 1:143 ISLAND VIEW CIR
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:SC
Mailing Address - Zip Code:29045-9182
Mailing Address - Country:US
Mailing Address - Phone:803-434-4838
Mailing Address - Fax:
Practice Address - Street 1:11 RICHLAND MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6863
Practice Address - Country:US
Practice Address - Phone:803-434-4838
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-10
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1158103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty