Provider Demographics
NPI:1346700275
Name:NEUROCOGNITIVE SPECIALTY GROUP, PLLC
Entity Type:Organization
Organization Name:NEUROCOGNITIVE SPECIALTY GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/CLINICAL NEUROPSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:WISDOM
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:888-606-0086
Mailing Address - Street 1:112 MAGNOLIA ESTATES DR
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-4613
Mailing Address - Country:US
Mailing Address - Phone:888-606-0086
Mailing Address - Fax:346-223-0296
Practice Address - Street 1:112 MAGNOLIA ESTATES DR
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-4613
Practice Address - Country:US
Practice Address - Phone:888-606-0086
Practice Address - Fax:346-223-0296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-25
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical NeurophysiologyGroup - Multi-Specialty