Provider Demographics
NPI:1740579069
Name:CLINICAL NEUROPSYCH, PA
Entity Type:Organization
Organization Name:CLINICAL NEUROPSYCH, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL NEUROPSYCHOLOGIST; OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:870-933-5174
Mailing Address - Street 1:1201 FLEMING AVE
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-4311
Mailing Address - Country:US
Mailing Address - Phone:870-933-5174
Mailing Address - Fax:
Practice Address - Street 1:1201 FLEMING AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-4311
Practice Address - Country:US
Practice Address - Phone:870-933-5174
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-07
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR09-61AE251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health