Provider Demographics
NPI:1245675784
Name:CORNERSTONE NEUROPSYCHOLOGY, LLC
Entity type:Organization
Organization Name:CORNERSTONE NEUROPSYCHOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDI
Authorized Official - Middle Name:NICHOLS
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:850-613-6677
Mailing Address - Street 1:1270 EGLIN PKWY
Mailing Address - Street 2:SUITE C-12
Mailing Address - City:SHALIMAR
Mailing Address - State:FL
Mailing Address - Zip Code:32579-2306
Mailing Address - Country:US
Mailing Address - Phone:850-613-6677
Mailing Address - Fax:850-613-6993
Practice Address - Street 1:1270 EGLIN PKWY
Practice Address - Street 2:SUITE C-12
Practice Address - City:SHALIMAR
Practice Address - State:FL
Practice Address - Zip Code:32579-2306
Practice Address - Country:US
Practice Address - Phone:850-613-6677
Practice Address - Fax:850-613-6993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-09
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7940103TM1800X, 103T00000X, 103G00000X, 103TF0200X, 103TB0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Single Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensicGroup - Single Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCD151ZMedicare UPIN