Basic Information
| Provider Information | |||||||||
| NPI: | 1962179770 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KEYSTONE NEUROPSYCHOLOGY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 BESSEMER RD STE 202 | ||||||||
| Address2: | |||||||||
| City: | MT PLEASANT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 156669122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4126554362 | ||||||||
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| Practice Location | |||||||||
| Address1: | 220 BESSEMER RD STE 202 | ||||||||
| Address2: | |||||||||
| City: | MT PLEASANT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 156669122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4126554362 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2021 | ||||||||
| LastUpdateDate: | 08/28/2021 | ||||||||
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| AuthorizedOfficialLastName: | BILLINGS | ||||||||
| AuthorizedOfficialFirstName: | KRISTYN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 4126554362 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | PS016829 | 01 | PA | STATE LICENSE | OTHER |