Provider Demographics
NPI:1013295450
Name:FLORIDA NEUROCOGNITIVE DEVELOPMENT CENTER
Entity Type:Organization
Organization Name:FLORIDA NEUROCOGNITIVE DEVELOPMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:ABBY
Authorized Official - Last Name:KOCH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:813-399-1625
Mailing Address - Street 1:3815 MARYWEATHER LN
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33544-7792
Mailing Address - Country:US
Mailing Address - Phone:813-399-1625
Mailing Address - Fax:813-873-8837
Practice Address - Street 1:3815 MARYWEATHER LN
Practice Address - Street 2:SUITE 101
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544-7792
Practice Address - Country:US
Practice Address - Phone:813-399-1625
Practice Address - Fax:813-873-8837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-03
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4230103TC2200X
FLSA3850235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty