Provider Demographics
NPI:1912308628
Name:NEUROFEEDBACK CENTERS OF UTAH
Entity Type:Organization
Organization Name:NEUROFEEDBACK CENTERS OF UTAH
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:435-216-7370
Mailing Address - Street 1:216 W SAINT GEORGE BLVD
Mailing Address - Street 2:B5
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-1308
Mailing Address - Country:US
Mailing Address - Phone:435-216-7370
Mailing Address - Fax:
Practice Address - Street 1:216 W SAINT GEORGE BLVD
Practice Address - Street 2:B5
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-1308
Practice Address - Country:US
Practice Address - Phone:435-216-7370
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-12
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT70746733902101Y00000X, 101YM0800X, 101YP2500X, 104100000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty