=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528518313
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KALAMAZOO NEUROFEEDBACK AND COUNSELING CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2016
-----------------------------------------------------
Last Update Date | 10/05/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 721 W CENTRE AVE
-----------------------------------------------------
City | PORTAGE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49024-5309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-330-7030
-----------------------------------------------------
Fax | 269-532-1907
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 721 W CENTRE AVE
-----------------------------------------------------
City | PORTAGE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49024-5309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-330-7030
-----------------------------------------------------
Fax | 269-532-1907
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER AND THERAPIST
-----------------------------------------------------
Name | MS. BARBARA JOANNE O'ROURKE
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 269-330-7030
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6801095473
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------