Provider Demographics
NPI:1750599981
Name:GREAT LAKES INSTITUTE FOR NEUROPSYCHOLOGY & BEHAVIORAL HEALTH
Entity type:Organization
Organization Name:GREAT LAKES INSTITUTE FOR NEUROPSYCHOLOGY & BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SANFORD
Authorized Official - Middle Name:LLOYD
Authorized Official - Last Name:PEDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:317-889-3901
Mailing Address - Street 1:PO BOX 750233
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45475-0233
Mailing Address - Country:US
Mailing Address - Phone:317-889-3901
Mailing Address - Fax:317-889-3902
Practice Address - Street 1:494 S EMERSON AVE
Practice Address - Street 2:SUITE C
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-1912
Practice Address - Country:US
Practice Address - Phone:317-889-3901
Practice Address - Fax:317-889-3902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-20
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensicGroup - Single Specialty
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealthGroup - Single Specialty
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth ServiceGroup - Single Specialty
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitationGroup - Single Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & AgingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200227370Medicaid