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General NPI Number Information
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NPI Number | 1881087369
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Entity Type | Organization
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Legal Business Name | CNS MEMORY CLINIC LLC
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Dates
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Enumeration Date | 03/09/2015
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Last Update Date | 10/19/2020
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Provider Practice Location Address
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Address Line | 2440 N LITCHFIELD RD STE 200
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City | GOODYEAR
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State | AZ
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Zip | 85395-1664
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Country | US
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Telephone | 623-977-6860
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Fax | 623-977-2016
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Provider Business Mailing Address
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Address Line | 2440 N LITCHFIELD RD STE 200
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City | GOODYEAR
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State | AZ
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Zip | 85395-1664
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Country | US
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Telephone | 623-977-6860
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Fax | 623-977-2016
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Authorized Official
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Title or Position | OWNER
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Name | DR. DANE A HIGGINS
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Credential | PHD
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Telephone | 623-977-6860
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 3656
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License Number State | AZ
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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 | 3656
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License Number State | AZ
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