Provider Demographics
NPI:1407678113
Name:NEURODIVERSE DIAGNOSTICS PLLC
Entity type:Organization
Organization Name:NEURODIVERSE DIAGNOSTICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DOREEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRANPEESHEH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:469-694-1754
Mailing Address - Street 1:996 ROYAL MARCO WAY
Mailing Address - Street 2:
Mailing Address - City:MARCO ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:34145-1829
Mailing Address - Country:US
Mailing Address - Phone:469-694-1754
Mailing Address - Fax:
Practice Address - Street 1:996 ROYAL MARCO WAY
Practice Address - Street 2:
Practice Address - City:MARCO ISLAND
Practice Address - State:FL
Practice Address - Zip Code:34145-1829
Practice Address - Country:US
Practice Address - Phone:469-694-1754
Practice Address - Fax:818-758-8015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-25
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty