=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497760102
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTER FOR BRAIN HEALTH INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2006
-----------------------------------------------------
Last Update Date | 02/25/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1840 MEASE DR SUITE 401A
-----------------------------------------------------
City | SAFETY HARBOR
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34695-6602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-669-7000
-----------------------------------------------------
Fax | 727-669-7002
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 956
-----------------------------------------------------
City | OLDSMAR
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34677-0956
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-669-7000
-----------------------------------------------------
Fax | 727-669-7002
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JESSICA LINDSTADT VASSALLO
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 727-669-7000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PY7281
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number | PY7281
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------