Provider Demographics
NPI:1881079184
Name:MENTAL EDGE NEUROPSYCHOLOGY
Entity type:Organization
Organization Name:MENTAL EDGE NEUROPSYCHOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NEUROPSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:DENBOER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:602-510-9217
Mailing Address - Street 1:PO BOX 967
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85001-0967
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16838 E PALISADES BLVD
Practice Address - Street 2:SUITE C153
Practice Address - City:FOUNTAIN HILLS
Practice Address - State:AZ
Practice Address - Zip Code:85268-3786
Practice Address - Country:US
Practice Address - Phone:602-510-9217
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-28
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4026103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty