Healthcare Provider Details

I. General information

NPI: 1477822823
Provider Name (Legal Business Name): BRAIN ANALYSIS AND NEURODEVELOPMENT CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2011
Last Update Date: 12/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 GATEHOUSE RD LOWER LEVEL
AMHERST MA
01002-2879
US

IV. Provider business mailing address

20 GATEHOUSE RD LOWER LEVEL
AMHERST MA
01002-2879
US

V. Phone/Fax

Practice location:
  • Phone: 413-835-0520
  • Fax: 413-835-0569
Mailing address:
  • Phone: 413-835-0520
  • Fax: 413-835-0569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number7324
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number8195
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number7324
License Number StateMA

VIII. Authorized Official

Name: DR. ROBERT W. DAVIS
Title or Position: DIRECTOR
Credential: PSY.D.
Phone: 413-835-0520