Provider Demographics
NPI:1710585997
Name:BLOOMINGTON NEUROFEEDBACK
Entity Type:Organization
Organization Name:BLOOMINGTON NEUROFEEDBACK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUDER
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:502-232-0405
Mailing Address - Street 1:1905 S LIBERTY DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-5146
Mailing Address - Country:US
Mailing Address - Phone:812-688-6220
Mailing Address - Fax:812-668-6225
Practice Address - Street 1:1905 S LIBERTY DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-5146
Practice Address - Country:US
Practice Address - Phone:812-668-6220
Practice Address - Fax:812-668-6225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-11
Last Update Date:2020-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)