Provider Demographics
NPI:1396991956
Name:NORTHEAST NEUROPSYCHOLOGY, LLC
Entity type:Organization
Organization Name:NORTHEAST NEUROPSYCHOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:KATY
Authorized Official - Middle Name:
Authorized Official - Last Name:JIMENEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-272-6007
Mailing Address - Street 1:609 W JOHNSON AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:CHESHIRE
Mailing Address - State:CT
Mailing Address - Zip Code:06410-4506
Mailing Address - Country:US
Mailing Address - Phone:203-272-6007
Mailing Address - Fax:203-272-8895
Practice Address - Street 1:609 W JOHNSON AVE STE 104
Practice Address - Street 2:
Practice Address - City:CHESHIRE
Practice Address - State:CT
Practice Address - Zip Code:06410-4506
Practice Address - Country:US
Practice Address - Phone:203-272-6007
Practice Address - Fax:203-272-8895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-14
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002206103G00000X
CT002847103G00000X
CT001864103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty