Provider Demographics
NPI:1356467419
Name:LONG ISLAND NEUROPSYCHOLOGY, P.C.
Entity Type:Organization
Organization Name:LONG ISLAND NEUROPSYCHOLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:S
Authorized Official - Last Name:BUSH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:631-334-7884
Mailing Address - Street 1:290 HAWKINS AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAKE RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-9600
Mailing Address - Country:US
Mailing Address - Phone:631-334-7884
Mailing Address - Fax:
Practice Address - Street 1:290 HAWKINS AVE
Practice Address - Street 2:SUITE B
Practice Address - City:LAKE RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-9600
Practice Address - Country:US
Practice Address - Phone:631-334-7884
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012998103G00000X, 103T00000X, 103TC0700X, 103TF0200X, 103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Not Answered103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensicGroup - Multi-Specialty
Not Answered103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitationGroup - Multi-Specialty