Provider Demographics
NPI:1972609204
Name:CAROLINA NEUROPSYCHOLOGICAL SERVICE, INC
Entity type:Organization
Organization Name:CAROLINA NEUROPSYCHOLOGICAL SERVICE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LAKE
Authorized Official - Last Name:CONDER
Authorized Official - Suffix:JR
Authorized Official - Credentials:PSYD
Authorized Official - Phone:919-859-9040
Mailing Address - Street 1:1540 SUNDAY DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-6000
Mailing Address - Country:US
Mailing Address - Phone:919-859-9040
Mailing Address - Fax:919-859-9030
Practice Address - Street 1:1540 SUNDAY DR
Practice Address - Street 2:SUITE 200
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6000
Practice Address - Country:US
Practice Address - Phone:919-859-9040
Practice Address - Fax:919-859-9030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0111103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1648Medicare ID - Type UnspecifiedMEDICARE