Healthcare Provider Details

I. General information

NPI: 1205359213
Provider Name (Legal Business Name): MEMORY CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2017
Last Update Date: 03/16/2021
Certification Date: 03/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

357 SHIELDS DR
BENNINGTON VT
05201-9810
US

IV. Provider business mailing address

357 SHIELDS DR
BENNINGTON VT
05201-9810
US

V. Phone/Fax

Practice location:
  • Phone: 802-447-1409
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. CYNTHIA MURPHY
Title or Position: DIRECTOR
Credential: PSYD, MBA
Phone: 802-447-1409