Healthcare Provider Details

I. General information

NPI: 1992558431
Provider Name (Legal Business Name): CEREBROFIT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2024
Last Update Date: 04/11/2024
Certification Date: 04/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2752 E PONCE DE LEON AVE STE G
DECATUR GA
30030-2714
US

IV. Provider business mailing address

3328 E PONCE DE LEON AVE UNIT 437
SCOTTSDALE GA
30079
US

V. Phone/Fax

Practice location:
  • Phone: 404-482-3898
  • Fax: 404-348-2359
Mailing address:
  • Phone:
  • Fax:

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
# 3
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name: VONETTA DOTSON
Title or Position: PRESIDENT
Credential: PHD
Phone: 352-213-0100