MEDICARE: FAYETTEVILLE NEUROPSYCHOLOGY PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103G00000X	Clinical Neuropsychologist	1853	NC

General Provider Information

NPI Number	:	1053830315
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAYETTEVILLE NEUROPSYCHOLOGY PLLC

Provider Business Mailing Address
First Line	:	2931 BREEZEWOOD AVE STE 100
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28303-5281
Country	:	US
Telephone Number	:	910-677-0000
Fax Number	:	910-677-0099

Provider Business Practice Location Address
First Line	:	2931 BREEZEWOOD AVE STE 100
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28303-5281
Country	:	US
Telephone Number	:	910-677-0000
Fax Number	:	910-677-0099

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MR. ROBERT R GAMBLE
Credential	:
Telephone Number	:	910-677-0000

Provider Enumeration Date	:	09/18/2017
Last Update Date	:	01/07/2021

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