Healthcare Provider Details

I. General information

NPI: 1669334827
Provider Name (Legal Business Name): BRAINLOGIX LAB, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2025
Last Update Date: 01/06/2026
Certification Date: 01/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 AVALON PARK EAST BLVD STE 200
ORLANDO FL
32828-4902
US

IV. Provider business mailing address

13001 FOUNDERS SQUARE DR STE 200
ORLANDO FL
32828-7708
US

V. Phone/Fax

Practice location:
  • Phone: 321-461-3202
  • Fax: 321-204-6855
Mailing address:
  • Phone: 321-461-3202
  • Fax: 321-204-6855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

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