Provider Demographics
NPI:1861636045
Name:UNIVERSITY NEUROPSYCHOLOGY, INC.
Entity Type:Organization
Organization Name:UNIVERSITY NEUROPSYCHOLOGY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MILES
Authorized Official - Middle Name:
Authorized Official - Last Name:TARTER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:617-877-5978
Mailing Address - Street 1:491 DUTTON ST
Mailing Address - Street 2:#304
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01854-4289
Mailing Address - Country:US
Mailing Address - Phone:617-877-5978
Mailing Address - Fax:206-666-3687
Practice Address - Street 1:364 HARVARD ST
Practice Address - Street 2:SUITE 1
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-2920
Practice Address - Country:US
Practice Address - Phone:617-877-5978
Practice Address - Fax:206-666-3687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-01
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8703103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1659498103OtherINDIVIDUAL NPI