MEDICARE: NEUROPSYCH WELLNESS 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

General Provider Information

NPI Number	:	1740914159
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEUROPSYCH WELLNESS LLC

Provider Business Mailing Address
First Line	:	110 E BROWARD BLVD STE 1700
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33301-3500
Country	:	US
Telephone Number	:	917-626-6017
Fax Number	:

Provider Business Practice Location Address
First Line	:	110 E BROWARD BLVD STE 1700
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33301-3500
Country	:	US
Telephone Number	:	917-626-6017
Fax Number	:

Authorized Official
Title or Position	:	NEUROPSYCHOLOGIST
Name	:	THEODOROS TSAOUSIDES
Credential	:	PH.D.
Telephone Number	:	917-626-6017

Provider Enumeration Date	:	07/12/2022
Last Update Date	:	07/12/2022

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