Healthcare Provider Details

I. General information

NPI: 1780141465
Provider Name (Legal Business Name): CHANGE COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2019
Last Update Date: 02/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750R MAIN ST
WILLIMANTIC CT
06226-2504
US

IV. Provider business mailing address

261 CHURCH ST
WILLIMANTIC CT
06226-2625
US

V. Phone/Fax

Practice location:
  • Phone: 860-833-2657
  • Fax:
Mailing address:
  • Phone: 860-833-2657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MADELYN BRIGGS
Title or Position: OWNER
Credential:
Phone: 860-833-2657