MEDICARE: CHANGE BEHAVIORAL HEALTH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	007967	IA

General Provider Information

NPI Number	:	1366782427
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHANGE BEHAVIORAL HEALTH

Provider Business Mailing Address
First Line	:	2315 FALLS AVE STE 1
Second Line	:
City	:	WATERLOO
State	:	IA
Zip	:	50701-5736
Country	:	US
Telephone Number	:	319-233-0323
Fax Number	:	319-233-5923

Provider Business Practice Location Address
First Line	:	2315 FALLS AVE STE 1
Second Line	:
City	:	WATERLOO
State	:	IA
Zip	:	50701-5736
Country	:	US
Telephone Number	:	319-233-0323
Fax Number	:	319-233-5923

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MISS SHANNON LEE HARRINGTON
Credential	:	BA,MA,MFT
Telephone Number	:	319-233-0323

Provider Enumeration Date	:	02/26/2013
Last Update Date	:	02/26/2013

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Directions to “CHANGE BEHAVIORAL HEALTH ” Practice Location

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