=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790570182
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COGNITIVE HOMEOSTASIS, LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2025
-----------------------------------------------------
Last Update Date | 04/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6590 WILLOW DALE CT
-----------------------------------------------------
City | LIBERTY TWP
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45011-9076
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-549-7414
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6590 WILLOW DALE CT
-----------------------------------------------------
City | LIBERTY TWP
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45011-9076
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-549-7414
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHIATRIC MENTAL HEALTH NP
-----------------------------------------------------
Name | KADORI NGIRABAKUNZI MARSHALL
-----------------------------------------------------
Credential | DNP, APRN-CNP, PMHNP
-----------------------------------------------------
Telephone | 513-549-7414
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------