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General NPI Number Information
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NPI Number | 1578999603
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Entity Type | Organization
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Legal Business Name | TARGETED NEUROFEEDBACK AND PSYCHOTHERAPY SERVICES, PLLC
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Dates
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Enumeration Date | 09/20/2013
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Last Update Date | 10/01/2015
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Provider Practice Location Address
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Address Line | 915 AIRPORT RD
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City | JACKSON
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State | MI
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Zip | 49202-1850
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Country | US
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Telephone | 517-740-6239
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Fax |
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Provider Business Mailing Address
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Address Line | 3008 S WOODDALE DR
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City | JACKSON
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State | MI
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Zip | 49203-3767
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Country | US
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Telephone | 517-740-6239
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | ERIC C MIKELAIT
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Credential | LMSW
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Telephone | 517-740-6239
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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 | E27191
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License Number State | MI
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