Provider Demographics
NPI:1003957879
Name:CENTER FOR COGNITIVE REHABILITATION
Entity Type:Organization
Organization Name:CENTER FOR COGNITIVE REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAGE
Authorized Official - Middle Name:G
Authorized Official - Last Name:WARE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-321-1441
Mailing Address - Street 1:1276 MCCONNELL DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-3506
Mailing Address - Country:US
Mailing Address - Phone:404-321-1441
Mailing Address - Fax:404-321-5876
Practice Address - Street 1:1276 MCCONNELL DR
Practice Address - Street 2:SUITE C
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-3506
Practice Address - Country:US
Practice Address - Phone:404-321-1441
Practice Address - Fax:404-321-5876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY000615103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP4415Medicare ID - Type UnspecifiedGROUP NUMBER