Provider Demographics
NPI:1023368016
Name:BROOKINGS NEUROPSYCHOLOGY SERVICES
Entity type:Organization
Organization Name:BROOKINGS NEUROPSYCHOLOGY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:RAUBY
Authorized Official - Last Name:SHAFFER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:605-692-6367
Mailing Address - Street 1:PO BOX 931
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57006-0931
Mailing Address - Country:US
Mailing Address - Phone:605-692-6367
Mailing Address - Fax:605-692-1883
Practice Address - Street 1:928 4TH ST
Practice Address - Street 2:SUITE 6
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57006-2171
Practice Address - Country:US
Practice Address - Phone:605-692-6367
Practice Address - Fax:605-692-1883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-17
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD472103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6552660Medicaid
S102729OtherMEDICARE PTAN/ID