Provider Demographics
NPI:1790133742
Name:BERKS NEUROPSYCHOLOGY, LLC
Entity Type:Organization
Organization Name:BERKS NEUROPSYCHOLOGY, LLC
Other - Org Name:DAVID E. NICODEMUS, JR.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:NICODEMUS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MA
Authorized Official - Phone:610-921-3172
Mailing Address - Street 1:700 CAROLINA AVE
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19605-1102
Mailing Address - Country:US
Mailing Address - Phone:610-921-3172
Mailing Address - Fax:610-796-6470
Practice Address - Street 1:1623 MORGANTOWN RD
Practice Address - Street 2:
Practice Address - City:READING
Practice Address - State:PA
Practice Address - Zip Code:19607-9455
Practice Address - Country:US
Practice Address - Phone:610-796-6422
Practice Address - Fax:610-796-6470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-01
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS007441L103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty