Healthcare Provider Details

I. General information

NPI: 1265434534
Provider Name (Legal Business Name): THE MEMORY DOCTOR, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 03/29/2021
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26540 ACE AVE STE E-106
LEESBURG FL
34748-8279
US

IV. Provider business mailing address

26540 ACE AVE STE E-106
LEESBURG FL
34748-8279
US

V. Phone/Fax

Practice location:
  • Phone: 352-530-2170
  • Fax: 352-530-2180
Mailing address:
  • Phone: 352-530-2170
  • Fax: 352-530-2180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPY6497
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY6497
License Number StateFL

VIII. Authorized Official

Name: BRENDA MASON
Title or Position: OFFICE MANAGER
Credential:
Phone: 352-530-2170