Healthcare Provider Details

I. General information

NPI: 1043348600
Provider Name (Legal Business Name): CLINICAL NEUROPSYCHOLOGICAL SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 04/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1045 MACKENZIE DR
LIMA OH
45805-1660
US

IV. Provider business mailing address

1045 MACKENZIE DR
LIMA OH
45805-1660
US

V. Phone/Fax

Practice location:
  • Phone: 419-222-5672
  • Fax: 419-222-6786
Mailing address:
  • Phone: 419-222-5672
  • Fax: 419-222-6786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. MATTHEW P ZICCARDI
Title or Position: OWNER
Credential: PSYD
Phone: 419-222-5672