Healthcare Provider Details

I. General information

NPI: 1093156630
Provider Name (Legal Business Name): NEUROPSYCHOLOGYCA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2013
Last Update Date: 01/23/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9663 SANTA MONICA BLVD # 1058
BEVERLY HILLS CA
90210-4303
US

IV. Provider business mailing address

9663 SANTA MONICA BLVD # 1058
BEVERLY HILLS CA
90210-4303
US

V. Phone/Fax

Practice location:
  • Phone: 424-245-5524
  • Fax:
Mailing address:
  • Phone: 424-245-5524
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number25773
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number25773
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. ALEXANDREA PARK
Title or Position: EXECUTIVE
Credential: PSY.D.
Phone: 424-245-5524