Healthcare Provider Details

I. General information

NPI: 1942912787
Provider Name (Legal Business Name): TAILS OF CHANGE: CHILD AND FAMILY THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2022
Last Update Date: 12/23/2022
Certification Date: 12/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20717 SOUTH ST STE D
TEHACHAPI CA
93561-6444
US

IV. Provider business mailing address

PO BOX 172
KEENE CA
93531-0172
US

V. Phone/Fax

Practice location:
  • Phone: 661-300-8257
  • Fax: 661-402-6503
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
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: JENNEFER LAWSON
Title or Position: CEO
Credential: LMFT
Phone: 661-300-8257