=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295229359
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTIAN PETER NITSCH PHD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2018
-----------------------------------------------------
Last Update Date | 09/14/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1942 CLAIRMONT RD
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30033-3406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-534-4579
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3641 MEDINA LINE RD
-----------------------------------------------------
City | RICHFIELD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44286-9544
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------