Basic Information
| Provider Information | |||||||||
| NPI: | 1275162281 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLACK SAND NEUROPSYCHOLOGICAL SERVICES, INC. | ||||||||
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| OtherOrganizationName: | BLACK SAND NEUROPSYCHOLOGICAL SERVICES, PC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4249 | ||||||||
| Address2: | |||||||||
| City: | HILO | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967200249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8083451726 | ||||||||
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| Practice Location | |||||||||
| Address1: | 25 KAHOA ST | ||||||||
| Address2: | |||||||||
| City: | HILO | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967202205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8083451726 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2020 | ||||||||
| LastUpdateDate: | 04/02/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FREEDLE | ||||||||
| AuthorizedOfficialFirstName: | LORRAINE | ||||||||
| AuthorizedOfficialMiddleName: | RAZZI | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8083451726 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | LCSW, PHD | ||||||||
| NPICertificationDate: | 04/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
No ID Information.