Healthcare Provider Details

I. General information

NPI: 1861874869
Provider Name (Legal Business Name): DEVELOPMENTAL NEUROPSYCHOLOGICAL SERVICES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2015
Last Update Date: 06/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3608 PLEASANT ST
SOUTH BEND IN
46615-2033
US

IV. Provider business mailing address

3608 PLEASANT ST
SOUTH BEND IN
46615-2033
US

V. Phone/Fax

Practice location:
  • Phone: 574-367-2371
  • Fax:
Mailing address:
  • Phone: 574-367-2371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number20042553A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20042553A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number20042553A
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number20042553A
License Number StateIN

VIII. Authorized Official

Name: CHAD EDWARDS
Title or Position: OWNER/PRESIDENT
Credential: PH.D.
Phone: 574-855-7169