Provider Demographics
NPI:1699494070
Name:SAN ELIJO NEUROFEEDBACK AND PSYCHOLOGICAL SERVICES
Entity type:Organization
Organization Name:SAN ELIJO NEUROFEEDBACK AND PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:CHARMAINE
Authorized Official - Middle Name:G
Authorized Official - Last Name:LOWE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:760-304-4168
Mailing Address - Street 1:1240 SAN ELIJO RD N
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-1086
Mailing Address - Country:US
Mailing Address - Phone:760-304-4168
Mailing Address - Fax:760-304-4168
Practice Address - Street 1:1240 SAN ELIJO RD N
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92078-1086
Practice Address - Country:US
Practice Address - Phone:760-304-4168
Practice Address - Fax:760-304-4168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-26
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health