Provider Demographics
NPI:1205540275
Name:THE BRAIN BALANCE CENTER INC
Entity type:Organization
Organization Name:THE BRAIN BALANCE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYNARD
Authorized Official - Suffix:
Authorized Official - Credentials:APCC
Authorized Official - Phone:095-530-3207
Mailing Address - Street 1:7512 N 133RD EAST AVE
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-7138
Mailing Address - Country:US
Mailing Address - Phone:909-438-0351
Mailing Address - Fax:
Practice Address - Street 1:7512 N 133RD EAST AVE
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-7138
Practice Address - Country:US
Practice Address - Phone:909-438-0351
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-13
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty