Provider Demographics
NPI:1508004540
Name:NEUROPSYCHOLOGICAL ASSOC OF CA-A PROFESSIONAL PSYCHOLOGICAL CORP
Entity Type:Organization
Organization Name:NEUROPSYCHOLOGICAL ASSOC OF CA-A PROFESSIONAL PSYCHOLOGICAL CORP
Other - Org Name:NEUROPSYCHOLOGICAL ASSOCIATES OF CA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:FRANCES
Authorized Official - Last Name:CRIMMINS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:707-526-5424
Mailing Address - Street 1:1260 N DUTTON AVE
Mailing Address - Street 2:STE 225
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-4659
Mailing Address - Country:US
Mailing Address - Phone:707-526-5424
Mailing Address - Fax:707-526-5900
Practice Address - Street 1:1260 N DUTTON AVE
Practice Address - Street 2:STE 225
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4659
Practice Address - Country:US
Practice Address - Phone:707-526-5424
Practice Address - Fax:707-526-5900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-29
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23205103G00000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY23205OtherPSYCHOLOGIST LICENSE