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General NPI Number Information
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NPI Number | 1801031042
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Entity Type | Organization
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Legal Business Name | LIFESPAN NEUROPSYCOLOGY, PC
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Dates
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Enumeration Date | 12/02/2008
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Last Update Date | 12/02/2008
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Provider Practice Location Address
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Address Line | 1060 EAST 86TH ST. SUITE 63D
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City | INDIANAPOLIS
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State | IN
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Zip | 46240-1831
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Country | US
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Telephone | 317-569-9922
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Fax | 317-962-1895
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Provider Business Mailing Address
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Address Line | 1427 WEST 86TH ST. SUITE 245
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City | INDIANAPOLIS
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State | IN
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Zip | 46260-2103
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Country | US
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Telephone | 317-569-9922
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Fax | 317-962-1895
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Authorized Official
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Title or Position | OWNER/PHSYICIAN
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Name | BRYAN A HUDSON
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Credential | PHD
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Telephone | 317-962-2594
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 20040858A
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License Number State | IN
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