Healthcare Provider Details

I. General information

NPI: 1497760102
Provider Name (Legal Business Name): CENTER FOR BRAIN HEALTH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 02/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1840 MEASE DR SUITE 401A
SAFETY HARBOR FL
34695-6602
US

IV. Provider business mailing address

PO BOX 956
OLDSMAR FL
34677-0956
US

V. Phone/Fax

Practice location:
  • Phone: 727-669-7000
  • Fax: 727-669-7002
Mailing address:
  • Phone: 727-669-7000
  • Fax: 727-669-7002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPY7281
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY7281
License Number StateFL

VIII. Authorized Official

Name: DR. JESSICA LINDSTADT VASSALLO
Title or Position: PRESIDENT
Credential: PHD
Phone: 727-669-7000