Provider Demographics
NPI:1700454642
Name:SOUTHWEST MICHIGAN NEUROPSYCHOLOGY PC
Entity Type:Organization
Organization Name:SOUTHWEST MICHIGAN NEUROPSYCHOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:FABIANO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:517-243-7027
Mailing Address - Street 1:238 HOOVER BLVD STE 20
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-3755
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:238 HOOVER BLVD STE 20
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-3755
Practice Address - Country:US
Practice Address - Phone:517-887-9801
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)