Healthcare Provider Details

I. General information

NPI: 1528469772
Provider Name (Legal Business Name): CHANGE ACADEMY LAKE OZARK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2014
Last Update Date: 05/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 CALO LN
LAKE OZARK MO
65049-9208
US

IV. Provider business mailing address

130 CALO LN
LAKE OZARK MO
65049-9208
US

V. Phone/Fax

Practice location:
  • Phone: 573-365-2221
  • Fax: 573-365-2224
Mailing address:
  • Phone: 573-365-2221
  • Fax: 573-365-2224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number016604
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number016604
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number016604
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number016604
License Number StateMO

VIII. Authorized Official

Name: DENISE HAGEMANN
Title or Position: OTR/L
Credential:
Phone: 573-552-8007