Healthcare Provider Details

I. General information

NPI: 1457406613
Provider Name (Legal Business Name): COURAGE TO CHANGE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

474 BARBOURVILLE RD SUITE 2
LONDON KY
40744-9302
US

IV. Provider business mailing address

474 BARBOURVILLE RD SUITE 2
LONDON KY
40744-9302
US

V. Phone/Fax

Practice location:
  • Phone: 606-877-9008
  • Fax: 606-877-1785
Mailing address:
  • Phone: 606-877-9008
  • Fax: 606-877-1785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number3300106600
License Number StateKY

VIII. Authorized Official

Name: MR. DAVID T TIPTON
Title or Position: EXECUTIVE DIRECTOR OWNER
Credential: LPC
Phone: 606-877-9008