Provider Demographics
NPI:1659747749
Name:COGNITIVE CARE PA
Entity Type:Organization
Organization Name:COGNITIVE CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSSILLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-579-2265
Mailing Address - Street 1:10950-60 SAN JOSE BLVD.
Mailing Address - Street 2:SUITE 169
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223
Mailing Address - Country:US
Mailing Address - Phone:904-770-5199
Mailing Address - Fax:
Practice Address - Street 1:4565 US HIGHWAY 17 STE 106
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-4822
Practice Address - Country:US
Practice Address - Phone:904-579-2265
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-12
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty