Healthcare Provider Details

I. General information

NPI: 1972640928
Provider Name (Legal Business Name): CLINICAL NEUROPSYCHOLOGY ASSOCIATES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 10/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1528 WALNUT ST SUITE 1500
PHILADELPHIA PA
19102-3604
US

IV. Provider business mailing address

PO BOX 359
FURLONG PA
18925-0359
US

V. Phone/Fax

Practice location:
  • Phone: 215-735-2505
  • Fax: 215-735-2504
Mailing address:
  • Phone: 215-735-2505
  • Fax: 215-735-2504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number004599L
License Number StatePA

VIII. Authorized Official

Name: EDWARD MAITZ
Title or Position: TREASURER
Credential: PHD
Phone: 215-735-2505