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General NPI Number Information
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NPI Number | 1114624277
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Entity Type | Organization
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Legal Business Name | PONTE VEDRA NEUROPSYCHOLOGY LLC
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Dates
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Enumeration Date | 02/09/2023
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Last Update Date | 02/09/2023
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Provider Practice Location Address
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Address Line | 4210 VALLEY RIDGE BLVD STE 113
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City | PONTE VEDRA
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State | FL
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Zip | 32081-5171
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Country | US
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Telephone | 904-303-8362
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Fax |
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Provider Business Mailing Address
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Address Line | 176 PARKBLUFF CIR
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City | PONTE VEDRA
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State | FL
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Zip | 32081-0958
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Country | US
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Telephone | 904-303-8362
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. KARI ENG
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Credential |
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Telephone | 904-303-8362
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number |
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License Number State |
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