Provider Demographics
NPI:1619902103
Name:NEUROPSYCHOLOGY & MEMORY CENTER, P.A.
Entity Type:Organization
Organization Name:NEUROPSYCHOLOGY & MEMORY CENTER, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JODY
Authorized Official - Middle Name:E
Authorized Official - Last Name:TALBOTT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:239-592-1771
Mailing Address - Street 1:4521 EXECUTIVE DR
Mailing Address - Street 2:SUITE # 204
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34119-9037
Mailing Address - Country:US
Mailing Address - Phone:239-592-1771
Mailing Address - Fax:239-592-0258
Practice Address - Street 1:4521 EXECUTIVE DR
Practice Address - Street 2:SUITE # 204
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34119-9037
Practice Address - Country:US
Practice Address - Phone:239-592-1771
Practice Address - Fax:239-592-0258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 7020103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU4063YOtherMEDICARE PTAN