Provider Demographics
NPI:1982143913
Name:INGENIUM NEUROPSYCHOLOGY LLC
Entity Type:Organization
Organization Name:INGENIUM NEUROPSYCHOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL NEUROPSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOANNA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:SALMON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, MBA
Authorized Official - Phone:617-895-8970
Mailing Address - Street 1:51 CHESTNUT ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-3873
Mailing Address - Country:US
Mailing Address - Phone:617-895-8970
Mailing Address - Fax:
Practice Address - Street 1:51 CHESTNUT ST
Practice Address - Street 2:SUITE 4
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-3873
Practice Address - Country:US
Practice Address - Phone:617-895-8970
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-23
Last Update Date:2017-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00498300103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1174801963Medicare PIN