Provider Demographics
| NPI: | 1548675077 |
|---|---|
| Name: | BLACK MOUNTAIN NEUROPSYCHOLOGY, PLLC |
| Entity type: | Organization |
| Organization Name: | BLACK MOUNTAIN NEUROPSYCHOLOGY, PLLC |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | MEMBER |
| Authorized Official - Prefix: | DR |
| Authorized Official - First Name: | KONSTANTINOS |
| Authorized Official - Middle Name: | D |
| Authorized Official - Last Name: | THOMOPOULOS |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | PSYD |
| Authorized Official - Phone: | 480-575-5700 |
| Mailing Address - Street 1: | 33755 N SCOTTSDALE RD |
| Mailing Address - Street 2: | SUITE J105 |
| Mailing Address - City: | SCOTTSDALE |
| Mailing Address - State: | AZ |
| Mailing Address - Zip Code: | 85266-1567 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 480-575-5700 |
| Mailing Address - Fax: | 866-307-0007 |
| Practice Address - Street 1: | 33755 N SCOTTSDALE RD |
| Practice Address - Street 2: | SUITE J105 |
| Practice Address - City: | SCOTTSDALE |
| Practice Address - State: | AZ |
| Practice Address - Zip Code: | 85266-1567 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 480-575-5700 |
| Practice Address - Fax: | 866-307-0007 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2014-06-23 |
| Last Update Date: | 2014-06-23 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 103G00000X | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | Group - Multi-Specialty | |
| No | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | Group - Multi-Specialty | |
| No | 103TA0400X | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
| No | 103TA0700X | Behavioral Health & Social Service Providers | Psychologist | Adult Development & Aging | Group - Multi-Specialty |
| No | 103TB0200X | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | Group - Multi-Specialty |
| No | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical | Group - Multi-Specialty |
| No | 103TC2200X | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | Group - Multi-Specialty |
| No | 103TF0000X | Behavioral Health & Social Service Providers | Psychologist | Family | Group - Multi-Specialty |
| No | 103TF0200X | Behavioral Health & Social Service Providers | Psychologist | Forensic | Group - Multi-Specialty |
| No | 103TH0004X | Behavioral Health & Social Service Providers | Psychologist | Health | Group - Multi-Specialty |
| No | 103TP2701X | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy | Group - Multi-Specialty |
| No | 103TR0400X | Behavioral Health & Social Service Providers | Psychologist | Rehabilitation | Group - Multi-Specialty |
