Provider Demographics
NPI:1578999603
Name:TARGETED NEUROFEEDBACK AND PSYCHOTHERAPY SERVICES, PLLC
Entity Type:Organization
Organization Name:TARGETED NEUROFEEDBACK AND PSYCHOTHERAPY SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:C
Authorized Official - Last Name:MIKELAIT
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:517-740-6239
Mailing Address - Street 1:3008 S WOODDALE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-3767
Mailing Address - Country:US
Mailing Address - Phone:517-740-6239
Mailing Address - Fax:
Practice Address - Street 1:915 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-1850
Practice Address - Country:US
Practice Address - Phone:517-740-6239
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-20
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIE271911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty