Provider Demographics
NPI:1598165920
Name:NEUROFEEDBACK ADDICTION RECOVERY
Entity Type:Organization
Organization Name:NEUROFEEDBACK ADDICTION RECOVERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:WARDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-216-7369
Mailing Address - Street 1:216 W SAINT GEORGE BLVD
Mailing Address - Street 2:SUITE B4
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-1308
Mailing Address - Country:US
Mailing Address - Phone:435-216-7369
Mailing Address - Fax:877-670-8957
Practice Address - Street 1:216 W SAINT GEORGE BLVD
Practice Address - Street 2:SUITE B4
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-1308
Practice Address - Country:US
Practice Address - Phone:435-216-7369
Practice Address - Fax:877-670-8957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-04
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT137026-3501101Y00000X, 101YA0400X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty