Healthcare Provider Details

I. General information

NPI: 1134718042
Provider Name (Legal Business Name): CHANGE THERAPEUTIC SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2021
Last Update Date: 01/14/2021
Certification Date: 01/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15447 ANACAPA RD STE D102
VICTORVILLE CA
92392-2481
US

IV. Provider business mailing address

15447 ANACAPA RD STE D102
VICTORVILLE CA
92392-2481
US

V. Phone/Fax

Practice location:
  • Phone: 90-965-4079
  • Fax: 800-915-8151
Mailing address:
  • Phone: 909-654-0798
  • Fax: 800-915-8151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: SHAREELA MARIE ALLEN
Title or Position: OWNER
Credential:
Phone: 909-654-0798