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General NPI Number Information
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NPI Number | 1174249015
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Entity Type | Organization
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Legal Business Name | MOHAVE NEUROFEEDBACK CLINIC, LLC
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Dates
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Enumeration Date | 10/12/2022
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Last Update Date | 03/17/2025
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Provider Practice Location Address
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Address Line | 2701 E ANDY DEVINE AVE STE 101
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City | KINGMAN
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State | AZ
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Zip | 86401-4889
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Country | US
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Telephone | 928-263-1045
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Fax | 928-597-5172
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Provider Business Mailing Address
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Address Line | 2701 E ANDY DEVINE AVE STE 101
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City | KINGMAN
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State | AZ
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Zip | 86401-4889
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Country | US
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Telephone | 928-263-1045
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Fax | 928-597-5172
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Authorized Official
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Title or Position | OWNER, COUNSELOR
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Name | AUDRA NICOLE JALBERT
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Credential | LPC
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Telephone | 928-263-1045
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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