MEDICARE: THE NEUROFORENSIC INSTITUTE AND THERAPEUTIC SERVICES INC.

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	PY7715	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1902112717
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE NEUROFORENSIC INSTITUTE AND THERAPEUTIC SERVICES INC.

Provider Business Mailing Address
First Line	:	8198 JOG RD
Second Line	:	SUITE 201
City	:	BOYNTON BEACH
State	:	FL
Zip	:	33472-2900
Country	:	US
Telephone Number	:	561-734-6118
Fax Number	:	561-963-3532

Provider Business Practice Location Address
First Line	:	8198 JOG RD
Second Line	:	SUITE 201
City	:	BOYNTON BEACH
State	:	FL
Zip	:	33472-2900
Country	:	US
Telephone Number	:	561-734-6118
Fax Number	:	561-963-3532

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. LISA CICETTI
Credential	:
Telephone Number	:	561-734-6118

Provider Enumeration Date	:	08/31/2010
Last Update Date	:	08/31/2010

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