Healthcare Provider Details

I. General information

NPI: 1366790941
Provider Name (Legal Business Name): PEDIATRIC NEUROPSYCHOLOGICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2012
Last Update Date: 08/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 S. MARSHALL SUITE G
ROGERSVILLE MO
65742
US

IV. Provider business mailing address

175 S. MARSHALL SUITE G
ROGERSVILLE MO
65742
US

V. Phone/Fax

Practice location:
  • Phone: 417-753-1963
  • Fax: 417-753-9405
Mailing address:
  • Phone: 417-753-1963
  • Fax: 417-753-9405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number2008011433
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number2008011433
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number2008011433
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number2008011433
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number2008011433
License Number StateMO
# 6
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2008011433
License Number StateMO

VIII. Authorized Official

Name: DR. DAWN H HUBER
Title or Position: MANAGING MEMBER
Credential: PHD
Phone: 417-753-1963