Provider Demographics
NPI:1265434534
Name:THE MEMORY DOCTOR, LLC
Entity type:Organization
Organization Name:THE MEMORY DOCTOR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-530-2170
Mailing Address - Street 1:26540 ACE AVE STE E-106
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-8279
Mailing Address - Country:US
Mailing Address - Phone:352-530-2170
Mailing Address - Fax:352-530-2180
Practice Address - Street 1:26540 ACE AVE STE E-106
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-8279
Practice Address - Country:US
Practice Address - Phone:352-530-2170
Practice Address - Fax:352-530-2180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-01
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6497103T00000X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherTAX ID NUMBER
FL=========OtherTAX ID NUMBER