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General NPI Number Information
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NPI Number | 1740579069
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Entity Type | Organization
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Legal Business Name | CLINICAL NEUROPSYCH, PA
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Dates
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Enumeration Date | 04/07/2011
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Last Update Date | 04/07/2011
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Provider Practice Location Address
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Address Line | 1201 FLEMING AVE
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City | JONESBORO
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State | AR
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Zip | 72401-4311
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Country | US
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Telephone | 870-933-5174
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Fax |
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Provider Business Mailing Address
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Address Line | 1201 FLEMING AVE
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City | JONESBORO
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State | AR
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Zip | 72401-4311
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Country | US
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Telephone | 870-933-5174
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Fax |
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Authorized Official
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Title or Position | CLINICAL NEUROPSYCHOLOGIST; OWNER
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Name | MR. DAN A JOHNSON
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Credential | PH.D.
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Telephone | 870-933-5174
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 09-61AE
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License Number State | AR
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