1184081564 NPI number — INNER CHANGELLC, COUNSELING AND EDUCATION CENTER

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 1184081564 NPI number — INNER CHANGELLC, COUNSELING AND EDUCATION CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INNER CHANGELLC, COUNSELING AND EDUCATION CENTER
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:
1184081564
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/15/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3600 DEKALB TECHNOLOGY PKWY
Provider Second Line Business Mailing Address:
SUITE140
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30340-3612
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-989-3114
Provider Business Mailing Address Fax Number:
470-282-5102

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3600 DEKALB TECHNOLOGY PKWY
Provider Second Line Business Practice Location Address:
SUITE140
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30340-3612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-989-3114
Provider Business Practice Location Address Fax Number:
470-282-5102
Provider Enumeration Date:
01/15/2016

Additional Information

Authorized Official

Authorized Official Last Name:
GATSON
Authorized Official First Name:
SHERRI
Authorized Official Middle Name:
ANNE
Authorized Official Title or Position:
CO-FOUNDER
Authorized Official Telephone Number:
404-989-3114

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  CSW001981 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 003136433A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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