Provider Demographics
NPI:1164591954
Name:FLORIDA ATLANTIC UNIVERSITY
Entity Type:Organization
Organization Name:FLORIDA ATLANTIC UNIVERSITY
Other - Org Name:MEMORY AND WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:LOUISA
Authorized Official - Middle Name:
Authorized Official - Last Name:PONTIROLI-KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-297-2897
Mailing Address - Street 1:777 GLADES RD
Mailing Address - Street 2:BLDG AZ-79
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-6424
Mailing Address - Country:US
Mailing Address - Phone:561-297-0502
Mailing Address - Fax:561-297-0505
Practice Address - Street 1:777 GLADES RD
Practice Address - Street 2:BLDG AZ-79
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-6424
Practice Address - Country:US
Practice Address - Phone:561-297-0502
Practice Address - Fax:561-297-0505
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FLORIDA ATLANTIC UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-07
Last Update Date:2023-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK3331Medicare ID - Type UnspecifiedGROUP NUMBER