MEDICARE: LONG ISLAND NEUROPSYCHOLOGY, P.C.

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	012998	NY
2	103T00000X	Psychologist	012998	NY
3	103TC0700X	Clinical Psychologist	012998	NY
4	103TR0400X	Rehabilitation Psychologist	012998	NY
5	103TF0200X	Forensic Psychologist	012998	NY

General Provider Information

NPI Number	:	1356467419
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LONG ISLAND NEUROPSYCHOLOGY, P.C.

Provider Business Mailing Address
First Line	:	290 HAWKINS AVE
Second Line	:	SUITE B
City	:	LAKE RONKONKOMA
State	:	NY
Zip	:	11779-9600
Country	:	US
Telephone Number	:	631-334-7884
Fax Number	:

Provider Business Practice Location Address
First Line	:	290 HAWKINS AVE
Second Line	:	SUITE B
City	:	LAKE RONKONKOMA
State	:	NY
Zip	:	11779-9600
Country	:	US
Telephone Number	:	631-334-7884
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. SHANE S. BUSH
Credential	:	PH.D.
Telephone Number	:	631-334-7884

Provider Enumeration Date	:	03/21/2007
Last Update Date	:	09/11/2025

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