MEDICARE: BRAINLOGIX LAB, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist
2	103G00000X	Clinical Neuropsychologist

General Provider Information

NPI Number	:	1669334827
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRAINLOGIX LAB, LLC

Provider Business Mailing Address
First Line	:	13001 FOUNDERS SQUARE DR STE 200
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32828-7708
Country	:	US
Telephone Number	:	321-461-3202
Fax Number	:	321-204-6855

Provider Business Practice Location Address
First Line	:	3801 AVALON PARK EAST BLVD STE 200
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32828-4902
Country	:	US
Telephone Number	:	321-461-3202
Fax Number	:	321-204-6855

Authorized Official
Title or Position	:	CLINICAL NEUROPSYCHOLOGIST
Name	:	DR. CHELSIE KAUILANI SIU-YIU SMYTH
Credential	:	PSYD
Telephone Number	:	321-461-3202

Provider Enumeration Date	:	11/25/2025
Last Update Date	:	11/25/2025

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