Healthcare Provider Details

I. General information

NPI: 1700437506
Provider Name (Legal Business Name): HEALTHY BRAIN AGING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2019
Last Update Date: 02/26/2020
Certification Date: 02/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14200 N NORTHSIGHT BLVD STE 100
SCOTTSDALE AZ
85260-3947
US

IV. Provider business mailing address

14200 N NORTHSIGHT BLVD STE 100
SCOTTSDALE AZ
85260-3947
US

V. Phone/Fax

Practice location:
  • Phone: 480-729-9610
  • Fax: 480-500-8345
Mailing address:
  • Phone: 480-729-9610
  • Fax: 480-500-8345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: EMILY A FAGER
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 480-729-9610