Healthcare Provider Details

I. General information

NPI: 1972609204
Provider Name (Legal Business Name): CAROLINA NEUROPSYCHOLOGICAL SERVICE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 SUNDAY DR SUITE 200
RALEIGH NC
27607-6000
US

IV. Provider business mailing address

1540 SUNDAY DR SUITE 200
RALEIGH NC
27607-6000
US

V. Phone/Fax

Practice location:
  • Phone: 919-859-9040
  • Fax: 919-859-9030
Mailing address:
  • Phone: 919-859-9040
  • Fax: 919-859-9030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number0111
License Number StateNC

VIII. Authorized Official

Name: DR. ROBERT LAKE CONDER JR.
Title or Position: PRESIDENT
Credential: PSY.D.
Phone: 919-859-9040