Provider Demographics
NPI:1801352695
Name:CAPITAL CITY NEUROPSYCHOLOGY, LLC
Entity type:Organization
Organization Name:CAPITAL CITY NEUROPSYCHOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL NEUROPSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:LARS
Authorized Official - Last Name:ROBERG
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:803-708-7095
Mailing Address - Street 1:6000 GARNERS FERRY RD STE 12
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29209-1303
Mailing Address - Country:US
Mailing Address - Phone:803-708-7095
Mailing Address - Fax:
Practice Address - Street 1:6000 GARNERS FERRY RD STE 12
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29209-1303
Practice Address - Country:US
Practice Address - Phone:803-790-7095
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-16
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty