Provider Demographics
NPI:1184466187
Name:FUNCTIONAL COGNITION CLINIC, LLC
Entity type:Organization
Organization Name:FUNCTIONAL COGNITION CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STANTON
Authorized Official - Middle Name:
Authorized Official - Last Name:SWANSON
Authorized Official - Suffix:
Authorized Official - Credentials:OTD
Authorized Official - Phone:678-773-9564
Mailing Address - Street 1:547 92ND AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-3033
Mailing Address - Country:US
Mailing Address - Phone:678-773-9564
Mailing Address - Fax:
Practice Address - Street 1:547 92ND AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-3033
Practice Address - Country:US
Practice Address - Phone:678-773-9564
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Multi-Specialty