Provider Demographics
NPI:1124527841
Name:CLINICAL & FORENSIC NEUROPSYCHOLOGY SERVICES LLC
Entity type:Organization
Organization Name:CLINICAL & FORENSIC NEUROPSYCHOLOGY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:HEATH
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:601-869-5898
Mailing Address - Street 1:PO BOX 2427
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39130-2427
Mailing Address - Country:US
Mailing Address - Phone:601-869-5898
Mailing Address - Fax:601-589-0825
Practice Address - Street 1:357 TOWNE CENTER BLVD STE 403
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-4844
Practice Address - Country:US
Practice Address - Phone:601-869-5898
Practice Address - Fax:601-589-0825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-08
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty