{
"Npi": {
"NPI": "1487015491",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "NEUROCORTEX PSYCHOLOGICAL SERVICES LLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "11520 SW 69TH CT",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "PINECREST",
"MailingAddressStateName": "FL",
"MailingAddressPostalCode": "33156-4734",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "305-669-2549",
"MailingAddressFaxNumber": "877-579-7427",
"FirstLinePracticeLocationAddress": "11520 SW 69TH CT",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "PINECREST",
"PracticeLocationAddressStateName": "FL",
"PracticeLocationAddressPostalCode": "33156-4734",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "305-669-2549",
"PracticeLocationAddressFaxNumber": "877-579-7427",
"EnumerationDate": "03/18/2016",
"LastUpdateDate": "05/19/2021",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "MOLINA",
"AuthorizedOfficialFirstName": "MARGIE",
"AuthorizedOfficialMiddleName": "MOLINET",
"AuthorizedOfficialTitle": "OPERATING MANAGER",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "PSYD",
"AuthorizedOfficialTelephoneNumber": "305-669-2549",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "103G00000X",
"TaxonomyName": "Clinical Neuropsychologist",
"LicenseNumber": "PY7041",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "103TC2200X",
"TaxonomyName": "Clinical Child & Adolescent Psychologist",
"LicenseNumber": "PY7041",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "103TC0700X",
"TaxonomyName": "Clinical Psychologist",
"LicenseNumber": "PY7041",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": [
{
"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
]
}
}
}