Provider Demographics
NPI:1871029074
Name:BRAIN WAVE PSYCHOLOGICAL NEUROTHERAPY ASSOCIATES INC.
Entity Type:Organization
Organization Name:BRAIN WAVE PSYCHOLOGICAL NEUROTHERAPY ASSOCIATES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:MCKINNEY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:818-821-6012
Mailing Address - Street 1:850 COLORADO BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:EAGLE ROCK
Mailing Address - State:CA
Mailing Address - Zip Code:90041-1733
Mailing Address - Country:US
Mailing Address - Phone:818-821-6012
Mailing Address - Fax:818-821-6014
Practice Address - Street 1:850 COLORADO BLVD 203
Practice Address - Street 2:
Practice Address - City:EAGLE ROCK
Practice Address - State:CA
Practice Address - Zip Code:90041-1733
Practice Address - Country:US
Practice Address - Phone:818-821-6012
Practice Address - Fax:818-821-6014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-08
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY28004103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty