Healthcare Provider Details

I. General information

NPI: 1316203706
Provider Name (Legal Business Name): CHANGE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2012
Last Update Date: 05/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1251 S MAIN ST
MIDDLETOWN CT
06457-5050
US

IV. Provider business mailing address

1251 S MAIN ST
MIDDLETOWN CT
06457-5050
US

V. Phone/Fax

Practice location:
  • Phone: 860-346-0771
  • Fax: 860-346-0772
Mailing address:
  • Phone: 860-346-0771
  • Fax: 860-346-0772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: MR. DERRICK CHRISTOPHER GIBBS JR.
Title or Position: PRESIDENT / C.E.O.
Credential:
Phone: 860-346-0771