​Rise N Shine Hypnosis and Counseling Super Bill

LPC-16270   Tax ID:  20 229 2013    NPI:  159 88 34160 
4215 N Brown Ave Suite D       Scottsdale, AZ 85251      gloriike@gmail.com

Client:

Diagnostic code:  F41.1 Generalized Anxiety Disorder   
 
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CPT Code: _______   Date of Service: _________ Fee:  _____
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                                                                       Total payment: 
90791  Initial Assessment   
90837  Individual session: 60 min  
90785  Interactive Complexity – add on code
                                                   
                 ________________________________________
          Gloria Eichenauer, Licensed Professional Counselor