Provider Demographics
NPI:1114624277
Name:PONTE VEDRA NEUROPSYCHOLOGY LLC
Entity Type:Organization
Organization Name:PONTE VEDRA NEUROPSYCHOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KARI
Authorized Official - Middle Name:
Authorized Official - Last Name:ENG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-303-8362
Mailing Address - Street 1:176 PARKBLUFF CIR
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081-0958
Mailing Address - Country:US
Mailing Address - Phone:904-303-8362
Mailing Address - Fax:
Practice Address - Street 1:4210 VALLEY RIDGE BLVD STE 113
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32081-5171
Practice Address - Country:US
Practice Address - Phone:904-303-8362
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-09
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty