Basic Information
| Provider Information | |||||||||
| NPI: | 1912160193 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NEUROSCIENCE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 CENTERVILLE RD | ||||||||
| Address2: | SUITE 504 | ||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323084647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504315001 | ||||||||
| FaxNumber: | 8504316101 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 CENTERVILLE RD | ||||||||
| Address2: | SUITE 504 | ||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323084647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504315001 | ||||||||
| FaxNumber: | 8504316101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2008 | ||||||||
| LastUpdateDate: | 07/08/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SHIPMAN | ||||||||
| AuthorizedOfficialFirstName: | JUDY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 8504315001 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TALLAHASSEE MEMORIAL HEALTHCARE | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 24766O | 01 | MEDICARE GROUP NUMBER | OTHER |