Healthcare Provider Details

I. General information

NPI: 1245675784
Provider Name (Legal Business Name): CORNERSTONE NEUROPSYCHOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2013
Last Update Date: 05/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1270 EGLIN PKWY SUITE C-12
SHALIMAR FL
32579-2306
US

IV. Provider business mailing address

1270 EGLIN PKWY SUITE C-12
SHALIMAR FL
32579-2306
US

V. Phone/Fax

Practice location:
  • Phone: 850-613-6677
  • Fax: 850-613-6993
Mailing address:
  • Phone: 850-613-6677
  • Fax: 850-613-6993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPY7940
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY7940
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPY7940
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY7940
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberPY7940
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License NumberPY7940
License Number StateFL

VIII. Authorized Official

Name: DR. RANDI NICHOLS MCDONALD
Title or Position: OWNER
Credential: PSY.D.
Phone: 850-613-6677