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General NPI Number Information
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NPI Number | 1710631205
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Entity Type | Organization
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Legal Business Name | BRAINIAC NEUROFEEDBACK COUNSELING AND COACHING
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Dates
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Enumeration Date | 02/04/2022
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Last Update Date | 02/04/2022
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Provider Practice Location Address
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Address Line | 9327 RAVENSWORTH CT
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City | MECHANICSVILLE
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State | VA
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Zip | 23116-8708
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Country | US
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Telephone | 804-357-2483
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Fax |
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Provider Business Mailing Address
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Address Line | 9327 RAVENSWORTH CT
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City | MECHANICSVILLE
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State | VA
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Zip | 23116-8708
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | CHERYL NORTH DESVERNINE
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Credential |
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Telephone | 804-357-2483
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084B0040X
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Taxonomy Name | Behavioral Neurology & Neuropsychiatry Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2084S0012X
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Taxonomy Name | Sleep Medicine (Psychiatry & Neurology) Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #5
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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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