Healthcare Provider Details

I. General information

NPI: 1134979644
Provider Name (Legal Business Name): GANESHA INSTITUTE OF NEUROLOGY AND PSYCHIATRY SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2024
Last Update Date: 01/17/2025
Certification Date: 01/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9327 N 3RD ST STE 200
PHOENIX AZ
85020-2473
US

IV. Provider business mailing address

PO BOX 14545
BELFAST ME
04915-4038
US

V. Phone/Fax

Practice location:
  • Phone: 847-816-6335
  • Fax:
Mailing address:
  • Phone: 847-816-6335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: LORI A SMITH
Title or Position: OFFICE MANAGER
Credential:
Phone: 847-816-6441