1952681504 NPI number — CENTER FOR LIFE CHANGE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952681504 NPI number — CENTER FOR LIFE CHANGE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTER FOR LIFE CHANGE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1952681504
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/24/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1103 EAST GRACE STREET
Provider Second Line Business Mailing Address:
BUILDING 2
Provider Business Mailing Address City Name:
RENSSELAER
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47978
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-866-7869
Provider Business Mailing Address Fax Number:
219-866-0688

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1317 15TH ST SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEMOTTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46310-9393
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-987-3719
Provider Business Practice Location Address Fax Number:
219-987-7729
Provider Enumeration Date:
08/26/2011

Additional Information

Authorized Official

Authorized Official Last Name:
GROVES
Authorized Official First Name:
LORI
Authorized Official Middle Name:
EILEEN
Authorized Official Title or Position:
MARRIAGE AND FAMILY THERAPIST
Authorized Official Telephone Number:
219-866-7869

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 201049690A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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