Provider Demographics
NPI:1659553444
Name:NEUROPSYCHOLOGY CLINIC PC
Entity Type:Organization
Organization Name:NEUROPSYCHOLOGY CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:P
Authorized Official - Last Name:KURTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-686-9005
Mailing Address - Street 1:3100 N DRIES LN
Mailing Address - Street 2:STE 303
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-1265
Mailing Address - Country:US
Mailing Address - Phone:309-686-9005
Mailing Address - Fax:309-686-9020
Practice Address - Street 1:3100 N DRIES LN
Practice Address - Street 2:STE 303
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-1265
Practice Address - Country:US
Practice Address - Phone:309-686-9005
Practice Address - Fax:309-686-9020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071004929103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
Z12891Medicare UPIN