Healthcare Provider Details

I. General information

NPI: 1841743762
Provider Name (Legal Business Name): THE LIFE CHANGE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2016
Last Update Date: 06/17/2024
Certification Date: 06/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 N STEWART ST STE 120
CARSON CITY NV
89706-3004
US

IV. Provider business mailing address

1755 SULLIVAN LN
SPARKS NV
89431-2815
US

V. Phone/Fax

Practice location:
  • Phone: 775-350-7250
  • Fax: 775-499-5535
Mailing address:
  • Phone: 775-499-5534
  • Fax: 775-499-5535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number8312NTC-01
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN FIRESTONE
Title or Position: EXECUTIVE DIRECTOR
Credential: MSW, LADC
Phone: 775-499-5534