Provider Demographics
NPI:1871700088
Name:MEMORY DISORDERS CLINIC
Entity type:Organization
Organization Name:MEMORY DISORDERS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:WENNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-203-2000
Mailing Address - Street 1:10915 264TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-9411
Mailing Address - Country:US
Mailing Address - Phone:320-293-2128
Mailing Address - Fax:
Practice Address - Street 1:1245 15TH ST N
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1802
Practice Address - Country:US
Practice Address - Phone:320-203-2093
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN100395225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty