Healthcare Provider Details

I. General information

NPI: 1215710819
Provider Name (Legal Business Name): COURAGE TO CHANGE CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2023
Last Update Date: 08/17/2023
Certification Date: 08/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2785 N MAIN ST STE 101B
HAZARD KY
41701-5910
US

IV. Provider business mailing address

311 WALKER LN
LONDON KY
40744-9036
US

V. Phone/Fax

Practice location:
  • Phone: 606-224-8451
  • Fax:
Mailing address:
  • Phone: 606-224-8451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: DAVID T TIPTON
Title or Position: OWNER/ PBSS
Credential: MA, LPCC
Phone: 606-224-8451