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General NPI Number Information
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NPI Number | 1053830315
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Entity Type | Organization
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Legal Business Name | FAYETTEVILLE NEUROPSYCHOLOGY PLLC
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Dates
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Enumeration Date | 09/18/2017
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Last Update Date | 01/07/2021
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Provider Practice Location Address
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Address Line | 2931 BREEZEWOOD AVE STE 100
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City | FAYETTEVILLE
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State | NC
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Zip | 28303-5281
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Country | US
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Telephone | 910-677-0000
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Fax | 910-677-0099
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Provider Business Mailing Address
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Address Line | 2931 BREEZEWOOD AVE STE 100
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City | FAYETTEVILLE
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State | NC
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Zip | 28303-5281
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Country | US
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Telephone | 910-677-0000
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Fax | 910-677-0099
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MR. ROBERT R GAMBLE
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Credential |
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Telephone | 910-677-0000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number | 1853
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License Number State | NC
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