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General NPI Number Information
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NPI Number | 1750599981
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Entity Type | Organization
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Legal Business Name | GREAT LAKES INSTITUTE FOR NEUROPSYCHOLOGY & BEHAVIORAL HEALTH
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Dates
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Enumeration Date | 05/20/2007
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Last Update Date | 06/07/2024
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Provider Practice Location Address
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Address Line | 494 S EMERSON AVE SUITE C
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City | GREENWOOD
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State | IN
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Zip | 46143-1912
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Country | US
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Telephone | 317-889-3901
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Fax | 317-889-3902
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Provider Business Mailing Address
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Address Line | PO BOX 750233
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City | DAYTON
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State | OH
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Zip | 45475-0233
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Country | US
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Telephone | 317-889-3901
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Fax | 317-889-3902
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. SANFORD LLOYD PEDERSON
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Credential | PH.D.
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Telephone | 317-889-3901
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103TF0200X
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Taxonomy Name | Forensic Psychologist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 103TH0004X
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Taxonomy Name | Health Psychologist
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 103TH0100X
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Taxonomy Name | Health Service Psychologist
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 103TR0400X
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Taxonomy Name | Rehabilitation Psychologist
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 103TA0700X
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Taxonomy Name | Adult Development & Aging Psychologist
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License Number |
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License Number State |
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Taxonomy #8
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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