Basic Information
Provider Information | |||||||||
NPI: | 1235542150 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NEA NEUROPSYCHOLOGY, PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
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OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 16374 | ||||||||
Address2: |   | ||||||||
City: | JONESBORO | ||||||||
State: | AR | ||||||||
PostalCode: | 724036706 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8702036085 | ||||||||
FaxNumber: | 8702036083 | ||||||||
Practice Location | |||||||||
Address1: | 304 SOUTHWEST SQ | ||||||||
Address2: |   | ||||||||
City: | JONESBORO | ||||||||
State: | AR | ||||||||
PostalCode: | 724015984 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8702036085 | ||||||||
FaxNumber: | 8702036083 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/09/2014 | ||||||||
LastUpdateDate: | 06/09/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HENDRIX | ||||||||
AuthorizedOfficialFirstName: | MARILYN | ||||||||
AuthorizedOfficialMiddleName: | MICHELLE | ||||||||
AuthorizedOfficialTitleorPosition: | OFFICE COORDINATOR | ||||||||
AuthorizedOfficialTelephone: | 8702036085 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
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AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 11-05P | AR | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103G00000X | 11-05P | AR | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |   |
No ID Information.