Provider Demographics
NPI:1972640928
Name:CLINICAL NEUROPSYCHOLOGY ASSOCIATES, P.C.
Entity type:Organization
Organization Name:CLINICAL NEUROPSYCHOLOGY ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:MAITZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:215-735-2505
Mailing Address - Street 1:PO BOX 359
Mailing Address - Street 2:
Mailing Address - City:FURLONG
Mailing Address - State:PA
Mailing Address - Zip Code:18925-0359
Mailing Address - Country:US
Mailing Address - Phone:215-735-2505
Mailing Address - Fax:215-735-2504
Practice Address - Street 1:1528 WALNUT ST
Practice Address - Street 2:SUITE 1500
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-3604
Practice Address - Country:US
Practice Address - Phone:215-735-2505
Practice Address - Fax:215-735-2504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA004599L103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1687168OtherPA BLUE SHIELD GROUP NUMB