Provider Demographics
NPI:1689181638
Name:LIFESPAN NEUROPSYCHOLOGY AND COUNSELING CENTER, LLC
Entity Type:Organization
Organization Name:LIFESPAN NEUROPSYCHOLOGY AND COUNSELING CENTER, LLC
Other - Org Name:LIFESPAN NEUROPSYCHOLOGY AND CLINICAL NEUROSCIENCE, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGIANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:DART
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:908-472-1255
Mailing Address - Street 1:2060 OAK TREE RD
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820
Mailing Address - Country:US
Mailing Address - Phone:908-472-1255
Mailing Address - Fax:848-200-7713
Practice Address - Street 1:2060 OAK TREE RD
Practice Address - Street 2:3RD FLOOR
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820
Practice Address - Country:US
Practice Address - Phone:908-472-1255
Practice Address - Fax:848-200-7713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-29
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ4987103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty