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General NPI Number Information
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NPI Number | 1104335694
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Entity Type | Organization
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Legal Business Name | PAINE CENTER FOR NEUROFEEDBACK LLC
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Dates
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Enumeration Date | 09/27/2017
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Last Update Date | 09/27/2017
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Provider Practice Location Address
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Address Line | 140 SHERMAN ST
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City | FAIRFIELD
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State | CT
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Zip | 06824-5849
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Country | US
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Telephone | 203-823-5109
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Fax |
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Provider Business Mailing Address
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Address Line | 31 COLONIAL HEIGHTS RD
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City | NORTH HAVEN
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State | CT
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Zip | 06473-4100
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Country | US
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Telephone | 203-823-5109
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | TARA PAINE
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Credential | LCSW
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Telephone | 203-823-5109
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 007720
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License Number State | CT
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