Provider Demographics
NPI:1710964218
Name:PEDIATRIC NEUROPSYCHOLOGY SERVICES, P.C.
Entity Type:Organization
Organization Name:PEDIATRIC NEUROPSYCHOLOGY SERVICES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVIDA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LP
Authorized Official - Phone:952-831-7400
Mailing Address - Street 1:4120 AVONDALE ST
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-1805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7200 FRANCE AVE S
Practice Address - Street 2:SUITE 128
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-4300
Practice Address - Country:US
Practice Address - Phone:952-831-7400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
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
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN116883OtherHEALTHPARTNERS
MN337G4PEOtherBLUE CROSS BLUE SHIELD
MN61-90675OtherMEDICA