Provider Demographics
NPI:1588091409
Name:CENTER FOR BRAINWAVE BALANCE PLLC
Entity type:Organization
Organization Name:CENTER FOR BRAINWAVE BALANCE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:HUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:734-585-0952
Mailing Address - Street 1:2245 S STATE ST
Mailing Address - Street 2:SUITE 1200 #1A
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-6184
Mailing Address - Country:US
Mailing Address - Phone:734-585-0952
Mailing Address - Fax:734-585-0954
Practice Address - Street 1:2245 S STATE ST
Practice Address - Street 2:SUITE 1200 #1A
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-6184
Practice Address - Country:US
Practice Address - Phone:734-585-0952
Practice Address - Fax:734-585-0954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-09
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5261103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty