Provider Demographics
NPI:1598015984
Name:NEUROPATH LLC
Entity Type:Organization
Organization Name:NEUROPATH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLEMENTE
Authorized Official - Middle Name:
Authorized Official - Last Name:VEGA
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:305-498-6050
Mailing Address - Street 1:106 QUEENSBERRY ST
Mailing Address - Street 2:# 18
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-4713
Mailing Address - Country:US
Mailing Address - Phone:305-498-6050
Mailing Address - Fax:
Practice Address - Street 1:106 QUEENSBERRY ST
Practice Address - Street 2:# 18
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-4713
Practice Address - Country:US
Practice Address - Phone:305-498-6050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9201103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty