Provider Demographics
NPI:1801031042
Name:LIFESPAN NEUROPSYCOLOGY, PC
Entity Type:Organization
Organization Name:LIFESPAN NEUROPSYCOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHSYICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:HUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:317-962-2594
Mailing Address - Street 1:1427 WEST 86TH ST.
Mailing Address - Street 2:SUITE 245
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-2103
Mailing Address - Country:US
Mailing Address - Phone:317-569-9922
Mailing Address - Fax:317-962-1895
Practice Address - Street 1:1060 EAST 86TH ST.
Practice Address - Street 2:SUITE 63D
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-1831
Practice Address - Country:US
Practice Address - Phone:317-569-9922
Practice Address - Fax:317-962-1895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-02
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040858A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty