Provider Demographics
NPI:1366790941
Name:PEDIATRIC NEUROPSYCHOLOGICAL SERVICES, LLC
Entity type:Organization
Organization Name:PEDIATRIC NEUROPSYCHOLOGICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:H
Authorized Official - Last Name:HUBER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:417-753-1963
Mailing Address - Street 1:175 S. MARSHALL
Mailing Address - Street 2:SUITE G
Mailing Address - City:ROGERSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65742
Mailing Address - Country:US
Mailing Address - Phone:417-753-1963
Mailing Address - Fax:417-753-9405
Practice Address - Street 1:175 S. MARSHALL
Practice Address - Street 2:SUITE G
Practice Address - City:ROGERSVILLE
Practice Address - State:MO
Practice Address - Zip Code:65742
Practice Address - Country:US
Practice Address - Phone:417-753-1963
Practice Address - Fax:417-753-9405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008011433103G00000X, 103TB0200X, 103TC2200X, 103TH0004X, 103TM1800X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealthGroup - Multi-Specialty
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Multi-Specialty