Healthcare Provider Details

I. General information

NPI: 1619475704
Provider Name (Legal Business Name): COGNITIVE CARE NETWORK, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2018
Last Update Date: 01/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3994 E AQUARIUS PL
CHANDLER AZ
85249-5896
US

IV. Provider business mailing address

3994 E AQUARIUS PL
CHANDLER AZ
85249-5896
US

V. Phone/Fax

Practice location:
  • Phone: 480-703-5905
  • Fax: 480-703-5905
Mailing address:
  • Phone: 480-703-5905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: SUZANNE JACOBS
Title or Position: OWNER/CLINICIAN
Credential: LCSW
Phone: 480-703-5905