=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053771196
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLINICAL PSYCHOLOGY SOLUTIONS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2016
-----------------------------------------------------
Last Update Date | 03/02/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 318 S B ST SUITE 5
-----------------------------------------------------
City | SAN MATEO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94401-4092
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-331-1503
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 318 S B ST SUITE 5
-----------------------------------------------------
City | SAN MATEO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94401-4092
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-331-1503
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | DR. ANNA NEDELISKY
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 917-331-1503
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number | PSY26298
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY26298
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------