MEDICARE: MEMORY BRIDGING INCORPORATED

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	103TB0200X	Cognitive & Behavioral Psychologist	803	CO

General Provider Information

NPI Number	:	1386827293
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEMORY BRIDGING INCORPORATED

Provider Business Mailing Address
First Line	:	141 MACK BAYOU LOOP
Second Line	:	SUITE 201
City	:	SANTA ROSA BEACH
State	:	FL
Zip	:	32459-7194
Country	:	US
Telephone Number	:	850-267-0030
Fax Number	:	850-267-0034

Provider Business Practice Location Address
First Line	:	16154 ROCK CRYSTAL DR
Second Line	:
City	:	PARKER
State	:	CO
Zip	:	80134-3305
Country	:	US
Telephone Number	:	303-328-1195
Fax Number	:	303-557-6240

Authorized Official
Title or Position	:	DIRECTOR OF ADMINISTRATION
Name	:	SUSANNE E BABER
Credential	:
Telephone Number	:	850-267-0030

Provider Enumeration Date	:	12/13/2007
Last Update Date	:	07/28/2009

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