Healthcare Provider Details

I. General information

NPI: 1548623812
Provider Name (Legal Business Name): MEANINGFUL CHANGE LEARNING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2016
Last Update Date: 06/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2892 PUEBLO BONITO
SANTA FE NM
87507-2549
US

IV. Provider business mailing address

2892 PUEBLO BONITO
SANTA FE NM
87507-2549
US

V. Phone/Fax

Practice location:
  • Phone: 508-733-6392
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-16-21909
License Number StateNM

VIII. Authorized Official

Name: SHANE KNOLL
Title or Position: CEO
Credential: BCBA
Phone: 508-665-8044