Provider Demographics
NPI:1760744718
Name:PEDIATRIC NEUROPSYCHOLOGY ASSOCIATES PLLC
Entity Type:Organization
Organization Name:PEDIATRIC NEUROPSYCHOLOGY ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC NEUROPSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLMQUIST-DAY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:405-713-7065
Mailing Address - Street 1:3330 NW 56TH ST
Mailing Address - Street 2:SUITE 305
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-4479
Mailing Address - Country:US
Mailing Address - Phone:405-713-7065
Mailing Address - Fax:405-713-7064
Practice Address - Street 1:3330 NW 56TH ST
Practice Address - Street 2:SUITE 305
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4479
Practice Address - Country:US
Practice Address - Phone:405-713-7065
Practice Address - Fax:405-713-7064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-14
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK944103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200013880BMedicaid