Provider Demographics
NPI:1114458478
Name:NEURO COG LLC
Entity type:Organization
Organization Name:NEURO COG LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/LICENSED HEALTH SERVICE PSYCH
Authorized Official - Prefix:MR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:H
Authorized Official - Last Name:MCCAFFREY
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHD
Authorized Official - Phone:405-329-7923
Mailing Address - Street 1:510 24TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-5106
Mailing Address - Country:US
Mailing Address - Phone:405-329-7923
Mailing Address - Fax:405-329-8815
Practice Address - Street 1:510 24TH AVE SW
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-5106
Practice Address - Country:US
Practice Address - Phone:405-329-7923
Practice Address - Fax:405-329-8815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-27
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3712101YP2500X
OK521103T00000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200709760AMedicaid