Healthcare Provider Details

I. General information

NPI: 1295229359
Provider Name (Legal Business Name): KRISTIAN PETER NITSCH PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2018
Last Update Date: 09/14/2020
Certification Date: 09/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1942 CLAIRMONT RD
DECATUR GA
30033-3406
US

IV. Provider business mailing address

3641 MEDINA LINE RD
RICHFIELD OH
44286-9544
US

V. Phone/Fax

Practice location:
  • Phone: 216-534-4579
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: