MEDICARE: BLOOMINGTON NEUROFEEDBACK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1710585997
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLOOMINGTON NEUROFEEDBACK

Provider Business Mailing Address
First Line	:	1905 S LIBERTY DR
Second Line	:
City	:	BLOOMINGTON
State	:	IN
Zip	:	47403-5146
Country	:	US
Telephone Number	:	812-688-6220
Fax Number	:	812-668-6225

Provider Business Practice Location Address
First Line	:	1905 S LIBERTY DR
Second Line	:
City	:	BLOOMINGTON
State	:	IN
Zip	:	47403-5146
Country	:	US
Telephone Number	:	812-668-6220
Fax Number	:	812-668-6225

Authorized Official
Title or Position	:	OWNER
Name	:	RHONDA SOUDER
Credential	:	LMHC
Telephone Number	:	502-232-0405

Provider Enumeration Date	:	10/11/2020
Last Update Date	:	10/11/2020

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Directions to “BLOOMINGTON NEUROFEEDBACK ” Practice Location

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