Healthcare Provider Details

I. General information

NPI: 1710690706
Provider Name (Legal Business Name): CHANGE ACADEMY AT LAKE OF THE OZARKS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2023
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11620 WILSHIRE BLVD STE 1150
LOS ANGELES CA
90025-1283
US

IV. Provider business mailing address

5500 MING AVE STE 410
BAKERSFIELD CA
93309-4631
US

V. Phone/Fax

Practice location:
  • Phone: 213-946-5247
  • Fax:
Mailing address:
  • Phone: 661-622-4132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: SHARNELL SPENCER
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 661-239-6923