Provider Demographics
NPI:1245701713
Name:MID ATLANTIC NEUROPSYCHOLOGY LLC
Entity type:Organization
Organization Name:MID ATLANTIC NEUROPSYCHOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:PRILUCK
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:410-205-9820
Mailing Address - Street 1:1501 SULGRAVE AVE STE 209
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-3650
Mailing Address - Country:US
Mailing Address - Phone:410-205-9820
Mailing Address - Fax:
Practice Address - Street 1:1501 SULGRAVE AVE STE 209
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-3650
Practice Address - Country:US
Practice Address - Phone:410-205-9820
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-10
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty