Healthcare Provider Details

I. General information

NPI: 1013295450
Provider Name (Legal Business Name): FLORIDA NEUROCOGNITIVE DEVELOPMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2011
Last Update Date: 08/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3815 MARYWEATHER LN SUITE 101
WESLEY CHAPEL FL
33544-7792
US

IV. Provider business mailing address

3815 MARYWEATHER LN SUITE 101
WESLEY CHAPEL FL
33544-7792
US

V. Phone/Fax

Practice location:
  • Phone: 813-399-1625
  • Fax: 813-873-8837
Mailing address:
  • Phone: 813-399-1625
  • Fax: 813-873-8837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPY4230
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA3850
License Number StateFL

VIII. Authorized Official

Name: DR. DIANE ABBY KOCH
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 813-399-1625