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General NPI Number Information
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NPI Number | 1659553444
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Entity Type | Organization
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Legal Business Name | NEUROPSYCHOLOGY CLINIC PC
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Dates
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Enumeration Date | 12/04/2007
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Last Update Date | 05/20/2013
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Provider Practice Location Address
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Address Line | 3100 N DRIES LN STE 303
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City | PEORIA
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State | IL
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Zip | 61604-1265
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Country | US
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Telephone | 309-686-9005
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Fax | 309-686-9020
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Provider Business Mailing Address
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Address Line | 3100 N DRIES LN STE 303
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City | PEORIA
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State | IL
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Zip | 61604-1265
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Country | US
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Telephone | 309-686-9005
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Fax | 309-686-9020
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MR. RODNEY P KURTH
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Credential |
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Telephone | 309-686-9005
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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 | 071004929
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License Number State | IL
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