Provider Demographics
NPI:1881087369
Name:CNS MEMORY CLINIC LLC
Entity type:Organization
Organization Name:CNS MEMORY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANE
Authorized Official - Middle Name:A
Authorized Official - Last Name:HIGGINS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:623-977-6860
Mailing Address - Street 1:2440 N LITCHFIELD RD STE 200
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-1664
Mailing Address - Country:US
Mailing Address - Phone:623-977-6860
Mailing Address - Fax:623-977-2016
Practice Address - Street 1:2440 N LITCHFIELD RD STE 200
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-1664
Practice Address - Country:US
Practice Address - Phone:623-977-6860
Practice Address - Fax:623-977-2016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-09
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3656103T00000X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ874322Medicaid
AZ874322Medicaid