Healthcare Provider Details

I. General information

NPI: 1720526387
Provider Name (Legal Business Name): A CHANGE OF MIND, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2017
Last Update Date: 01/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5020 TAMIAMI TRAIL N SUITE 202
NAPLES FL
34103
US

IV. Provider business mailing address

5020 TAMIAMI TRAIL N SUITE 202
NAPLES FL
34103
US

V. Phone/Fax

Practice location:
  • Phone: 239-260-4387
  • Fax: 844-715-9627
Mailing address:
  • Phone: 239-260-4387
  • Fax: 844-715-9627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW9293
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberSW9293
License Number StateFL

VIII. Authorized Official

Name: MRS. HEIDI ANN WILSON
Title or Position: OWNER
Credential: LCSW
Phone: 239-260-4387