Provider Demographics
NPI:1730480591
Name:BRAIN FUNCTION CLINIC
Entity Type:Organization
Organization Name:BRAIN FUNCTION CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER SOLE PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:KALTER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:239-403-8883
Mailing Address - Street 1:27499 RIVERVIEW CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134-4313
Mailing Address - Country:US
Mailing Address - Phone:239-403-8883
Mailing Address - Fax:239-403-8881
Practice Address - Street 1:27499 RIVERVIEW CENTER BLVD
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-4313
Practice Address - Country:US
Practice Address - Phone:239-403-8883
Practice Address - Fax:239-403-8881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-10
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5251103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL59727OtherBLUE CROSS
FL59727AMedicare PIN