Provider Demographics
NPI:1184317760
Name:ARIZONA NEUROPSYCHOLOGY INSTITUTE
Entity type:Organization
Organization Name:ARIZONA NEUROPSYCHOLOGY INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:
Authorized Official - Last Name:ETLING
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:480-630-7747
Mailing Address - Street 1:24654 N LAKE PLEASANT PKWY STE 103-466
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-1359
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11225 N 28TH DR STE B125
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-5606
Practice Address - Country:US
Practice Address - Phone:480-630-7747
Practice Address - Fax:480-630-7748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-31
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty