MEDICARE: NEUROFEEDBACK COLORADO SPRINGS, INC.

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	103TC2200X	Clinical Child & Adolescent Psychologist	4106	CO
2	103G00000X	Clinical Neuropsychologist	4106	CO
3	103TC0700X	Clinical Psychologist	1577	HI
4	103TC0700X	Clinical Psychologist	4106	CO

General Provider Information

NPI Number	:	1972048098
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEUROFEEDBACK COLORADO SPRINGS, INC.

Provider Business Mailing Address
First Line	:	1283 KELLY JOHNSON BLVD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80920-3925
Country	:	US
Telephone Number	:	719-639-2928
Fax Number	:	719-203-6847

Provider Business Practice Location Address
First Line	:	1283 KELLY JOHNSON BLVD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80920-3925
Country	:	US
Telephone Number	:	719-639-2928
Fax Number	:	719-203-6847

Authorized Official
Title or Position	:	LICENSED PSYCHOLOGIST
Name	:	DR. EMILY INMAN
Credential	:	PSYD
Telephone Number	:	712-209-0399

Provider Enumeration Date	:	12/28/2016
Last Update Date	:	12/18/2020

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