Provider Demographics
NPI:1366272106
Name:MAST MEMORY AND PSYCHOLOGICAL SERVICES
Entity type:Organization
Organization Name:MAST MEMORY AND PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:T
Authorized Official - Last Name:MAST
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, ABPP
Authorized Official - Phone:502-632-7817
Mailing Address - Street 1:6000 BROWNSBORO PARK BLVD STE G
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-7201
Mailing Address - Country:US
Mailing Address - Phone:502-632-7817
Mailing Address - Fax:502-721-0333
Practice Address - Street 1:6000 BROWNSBORO PARK BLVD STE G
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-7201
Practice Address - Country:US
Practice Address - Phone:502-632-7817
Practice Address - Fax:502-721-0333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-06
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty