Healthcare Provider Details

I. General information

NPI: 1851147482
Provider Name (Legal Business Name): STABLE CHANGE BEHAVIORAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2024
Last Update Date: 04/25/2024
Certification Date: 04/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

937 COUNTY ROAD 43
SAMSON AL
36477-5747
US

IV. Provider business mailing address

937 COUNTY ROAD 43
SAMSON AL
36477-5747
US

V. Phone/Fax

Practice location:
  • Phone: 541-591-9712
  • Fax:
Mailing address:
  • Phone: 541-591-9712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: JESSICA M KELLEY
Title or Position: OWNER/CLINICAL DIRECTOR
Credential: MSMFT
Phone: 541-591-9712