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General NPI Number Information
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NPI Number | 1114396835
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Entity Type | Organization
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Legal Business Name | MONTCLAIR MEMORY CLINIC LLC
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Dates
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Enumeration Date | 09/23/2015
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Last Update Date | 04/15/2016
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Provider Practice Location Address
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Address Line | 70 PARK STREET SUITE 207
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City | MONTCLAIR
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State | NJ
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Zip | 07042-2960
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Country | US
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Telephone | 973-743-4555
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Fax | 973-743-4055
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Provider Business Mailing Address
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Address Line | PO BOX 8121
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City | GLEN RIDGE
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State | NJ
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Zip | 07028-8121
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Country | US
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Telephone | 973-743-4555
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Fax | 973-743-4055
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Authorized Official
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Title or Position | CLINICAL DIRECTOR
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Name | JACQUELINE A RONDEAU
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Credential | PSYD
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Telephone | 973-743-4555
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 35SI00390000
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License Number State | NJ
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Taxonomy #2
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number | 35SI00390000
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License Number State | NJ
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