Healthcare Provider Details

I. General information

NPI: 1902280126
Provider Name (Legal Business Name): EAST ALABAMA CENTER FOR CHANGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2015
Last Update Date: 07/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 BRAGG AVE
AUBURN AL
36830-3809
US

IV. Provider business mailing address

124 BRAGG AVE
AUBURN AL
36830-3809
US

V. Phone/Fax

Practice location:
  • Phone: 334-734-2603
  • Fax: 334-887-0031
Mailing address:
  • Phone: 334-734-2603
  • Fax: 334-887-0031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberAL1749
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License NumberAL1749
License Number StateAL

VIII. Authorized Official

Name: AMBER ELIZABETH DOUGLAS
Title or Position: LICENSED PSYCHOLOGIST
Credential: PSYD
Phone: 334-734-2603