Healthcare Provider Details

I. General information

NPI: 1235542150
Provider Name (Legal Business Name): NEA NEUROPSYCHOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2014
Last Update Date: 06/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 SOUTHWEST SQ
JONESBORO AR
72401-5984
US

IV. Provider business mailing address

PO BOX 16374
JONESBORO AR
72403-6706
US

V. Phone/Fax

Practice location:
  • Phone: 870-203-6085
  • Fax: 870-203-6083
Mailing address:
  • Phone: 870-203-6085
  • Fax: 870-203-6083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number11-05P
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number11-05P
License Number StateAR

VIII. Authorized Official

Name: MARILYN MICHELLE HENDRIX
Title or Position: OFFICE COORDINATOR
Credential:
Phone: 870-203-6085