Provider Demographics
NPI:1043639818
Name:MEMPHIS INTEGRAL NEUROFEEDBACK INSTITUTE LLC
Entity type:Organization
Organization Name:MEMPHIS INTEGRAL NEUROFEEDBACK INSTITUTE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:SHERROD
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:901-624-0100
Mailing Address - Street 1:758 WALNUT KNOLL LN
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-3112
Mailing Address - Country:US
Mailing Address - Phone:901-624-0100
Mailing Address - Fax:901-624-0778
Practice Address - Street 1:758 WALNUT KNOLL LN
Practice Address - Street 2:SUITE 101
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-3112
Practice Address - Country:US
Practice Address - Phone:901-624-0100
Practice Address - Fax:901-624-0778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-09
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP1439103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty