MEDICARE: CLINICAL NEUROPSYCHOLOGY PC

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	103TC0700X	Clinical Psychologist

General Provider Information

NPI Number	:	1689058414
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLINICAL NEUROPSYCHOLOGY PC

Provider Business Mailing Address
First Line	:	218 W WASHINGTON ST
Second Line	:	SUITE 800
City	:	SOUTH BEND
State	:	IN
Zip	:	46601-1800
Country	:	US
Telephone Number	:	574-232-4453
Fax Number	:	574-232-7718

Provider Business Practice Location Address
First Line	:	218 W WASHINGTON ST
Second Line	:	SUITE 800
City	:	SOUTH BEND
State	:	IN
Zip	:	46601-1800
Country	:	US
Telephone Number	:	574-232-4453
Fax Number	:	574-232-7718

Authorized Official
Title or Position	:	OWNER
Name	:	DR. WARREN W SIBILLA JR.
Credential	:	PH.D.
Telephone Number	:	574-232-4453

Provider Enumeration Date	:	07/10/2015
Last Update Date	:	07/10/2015

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