Organization
GREAT LAKES INSTITUTE FOR NEUROPSYCHOLOGY & BEHAVIORAL HEALTH
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. SANFORD LLOYD PEDERSON PH.D. (PRESIDENT)
(317) 889-3901
Entity
Organization
Contact information
Practice address
494 S EMERSON AVE, SUITE C, GREENWOOD, IN 46143-1912
(317) 889-3901
(317) 889-3902
Mailing address
PO BOX 750233, DAYTON, OH 45475-0233
(317) 889-3901
(317) 889-3902
Taxonomy
Speciality
Code
Description
License number
State
103G00000X
Clinical Neuropsychologist
—
—
103TA0700X
Adult Development & Aging Psychologist
—
—
103TC0700X
Clinical Psychologist
Primary
—
—
103TC2200X
Clinical Child & Adolescent Psychologist
—
—
103TF0200X
Forensic Psychologist
—
—
103TH0004X
Health Psychologist
—
—
103TH0100X
Health Service Psychologist
—
—
103TR0400X
Rehabilitation Psychologist
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200227370
—
IN
Enumeration date
05/20/2007
Last updated
06/07/2024
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