Provider Demographics
NPI:1700403672
Name:NEUROEDGE PSYCHOLOGY LLC
Entity Type:Organization
Organization Name:NEUROEDGE PSYCHOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GENDRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTESINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-442-5424
Mailing Address - Street 1:3373 W 90TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33018-2005
Mailing Address - Country:US
Mailing Address - Phone:786-442-5424
Mailing Address - Fax:
Practice Address - Street 1:3373 W 90TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33018-2005
Practice Address - Country:US
Practice Address - Phone:786-442-5424
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-26
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty