Healthcare Provider Details

I. General information

NPI: 1255071304
Provider Name (Legal Business Name): TIME 4 CHANGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2022
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 BLUE HARVEST LP
SANTA FE NM
87506
US

IV. Provider business mailing address

PO BOX 1631
ESPANOLA NM
87532-1631
US

V. Phone/Fax

Practice location:
  • Phone: 505-709-0608
  • Fax:
Mailing address:
  • Phone: 505-709-0608
  • 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 Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. TROY CAMPBELL
Title or Position: OWNER/CLINICIAN
Credential: DBH, LCSW
Phone: 505-709-0608