Basic Information
| Provider Information | |||||||||
| NPI: | 1790133742 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BERKS NEUROPSYCHOLOGY, LLC | ||||||||
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| OtherOrganizationName: | DAVID E. NICODEMUS, JR. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 CAROLINA AVE | ||||||||
| Address2: | |||||||||
| City: | READING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 196051102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109213172 | ||||||||
| FaxNumber: | 6107966470 | ||||||||
| Practice Location | |||||||||
| Address1: | 1623 MORGANTOWN RD | ||||||||
| Address2: | |||||||||
| City: | READING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 196079455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6107966422 | ||||||||
| FaxNumber: | 6107966470 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2016 | ||||||||
| LastUpdateDate: | 06/01/2016 | ||||||||
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| AuthorizedOfficialLastName: | NICODEMUS | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | EDWARD | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6109213172 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | M.A. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PS007441L | PA | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103G00000X | PS007441L | PA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
No ID Information.