Provider Demographics
NPI:1174059851
Name:KNOXVILLE NEUROFEEDBACK GROUP
Entity type:Organization
Organization Name:KNOXVILLE NEUROFEEDBACK GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:S
Authorized Official - Last Name:CARROLL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:865-661-1929
Mailing Address - Street 1:7417 KINGSTON PIKE STE 103
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37919-5616
Mailing Address - Country:US
Mailing Address - Phone:865-661-1829
Mailing Address - Fax:865-579-2522
Practice Address - Street 1:7417 KINGSTON PIKE STE 103
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-5616
Practice Address - Country:US
Practice Address - Phone:865-661-1829
Practice Address - Fax:865-579-2522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-02
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP0000002366261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)