Basic Information
| Provider Information | |||||||||
| NPI: | 1790023851 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BAY AREA NEUROPSYCHOLOGY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2919 W SWANN AVE STE 201 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336094050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8133815200 | ||||||||
| FaxNumber: | 8133815200 | ||||||||
| Practice Location | |||||||||
| Address1: | 2919 W SWANN AVE STE 201 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336094050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8133815200 | ||||||||
| FaxNumber: | 8133815200 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2013 | ||||||||
| LastUpdateDate: | 10/25/2021 | ||||||||
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| AuthorizedOfficialLastName: | INGULLI | ||||||||
| AuthorizedOfficialFirstName: | LAMAR | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/NEUROPSYCHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 8133815200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PSY.D. | ||||||||
| NPICertificationDate: | 10/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 103G00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103TC0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC2200X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 103TF0200X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Forensic | 103TM1800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Mental Retardation & Developmental Disabilities | 103T00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.