Healthcare Provider Details

I. General information

NPI: 1346700275
Provider Name (Legal Business Name): NEUROCOGNITIVE SPECIALTY GROUP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2019
Last Update Date: 10/11/2023
Certification Date: 10/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 MAGNOLIA ESTATES DR
LEAGUE CITY TX
77573-4613
US

IV. Provider business mailing address

112 MAGNOLIA ESTATES DR
LEAGUE CITY TX
77573-4613
US

V. Phone/Fax

Practice location:
  • Phone: 888-606-0086
  • Fax: 346-223-0296
Mailing address:
  • Phone: 888-606-0086
  • Fax: 346-223-0296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State

VIII. Authorized Official

Name: NICHOLAS WISDOM
Title or Position: DIRECTOR/CLINICAL NEUROPSYCHOLOGIST
Credential: PHD
Phone: 888-606-0086