Provider Demographics
NPI:1043348600
Name:CLINICAL NEUROPSYCHOLOGICAL SERVICES, INC.
Entity type:Organization
Organization Name:CLINICAL NEUROPSYCHOLOGICAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:P
Authorized Official - Last Name:ZICCARDI
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:419-222-5672
Mailing Address - Street 1:1045 MACKENZIE DR
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-1660
Mailing Address - Country:US
Mailing Address - Phone:419-222-5672
Mailing Address - Fax:419-222-6786
Practice Address - Street 1:1045 MACKENZIE DR
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45805-1660
Practice Address - Country:US
Practice Address - Phone:419-222-5672
Practice Address - Fax:419-222-6786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCL9305941Medicare ID - Type Unspecified
OHCK8180Medicare ID - Type UnspecifiedMEDICARE RAILROAD