Healthcare Provider Details

I. General information

NPI: 1114330701
Provider Name (Legal Business Name): THE INSTITUTE FOR CLINICAL NEURSOCIENCE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2014
Last Update Date: 10/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4425 W AIRPORT FWY SUITE 250
IRVING TX
75062-5832
US

IV. Provider business mailing address

PO BOX 25339
COLORADO SPRINGS CO
80936-5339
US

V. Phone/Fax

Practice location:
  • Phone: 817-306-0215
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code209800000X
TaxonomyLegal Medicine (M.D./D.O.) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State

VIII. Authorized Official

Name: MRS. DEE DOBBS
Title or Position: CREDENTILING
Credential:
Phone: 817-306-0215