Healthcare Provider Details

I. General information

NPI: 1710493143
Provider Name (Legal Business Name): NEW CONCEPTS FOR CHANGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2017
Last Update Date: 12/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 WABASH AVE
TERRE HAUTE IN
47807-3325
US

IV. Provider business mailing address

1800 WABASH AVE
TERRE HAUTE IN
47807-3325
US

V. Phone/Fax

Practice location:
  • Phone: 812-235-8744
  • Fax: 812-282-7258
Mailing address:
  • Phone: 812-235-8744
  • Fax: 812-282-7258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number87001381A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34006237A
License Number StateIN

VIII. Authorized Official

Name: MS. KIMBERLI RAE PEPELEA
Title or Position: CEO
Credential: LCSW
Phone: 812-235-8744