Basic Information
| Provider Information | |||||||||
| NPI: | 1285111997 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SIERRA NEVADA NEUROPSYCHOLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 177 BOVET RD FL 6 | ||||||||
| Address2: | |||||||||
| City: | SAN MATEO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 944023122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8885701020 | ||||||||
| FaxNumber: | 8883840984 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 E MAIN ST STE 106 | ||||||||
| Address2: | |||||||||
| City: | GRASS VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959455853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5304466164 | ||||||||
| FaxNumber: | 5304466377 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2018 | ||||||||
| LastUpdateDate: | 05/12/2020 | ||||||||
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| AuthorizedOfficialLastName: | SNYDER | ||||||||
| AuthorizedOfficialFirstName: | JODI | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER | ||||||||
| AuthorizedOfficialTelephone: | 5304466164 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PSYD | ||||||||
| NPICertificationDate: | 05/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.