MEDICARE: COGNITIVE CONSULTS AND TECHNOLOGY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103G00000X	Clinical Neuropsychologist	0810004396	VA

General Provider Information

NPI Number	:	1003330408
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COGNITIVE CONSULTS AND TECHNOLOGY LLC

Provider Business Mailing Address
First Line	:	3604 WHITEHAVEN PKWY NW
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20007
Country	:	US
Telephone Number	:	410-808-4667
Fax Number	:	202-621-7666

Provider Business Practice Location Address
First Line	:	3020 HAMAKER COURT, SUITE 103
Second Line	:	NEUROPSYCHOLOGY ASSOCIATES OF FAIRFAX
City	:	FAIRFAX
State	:	VA
Zip	:	22031
Country	:	US
Telephone Number	:	703-876-0966
Fax Number	:	703-876-1628

Authorized Official
Title or Position	:	CEO
Name	:	DR. ROBERT L KANE
Credential	:	PH.D.
Telephone Number	:	410-808-4667

Provider Enumeration Date	:	07/28/2017
Last Update Date	:	07/28/2017

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