Healthcare Provider Details

I. General information

NPI: 1780363044
Provider Name (Legal Business Name): CHANGE AGENTS OF SOCIAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2023
Last Update Date: 07/13/2023
Certification Date: 07/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2709 POSITIVE CT
NORTH LAS VEGAS NV
89031-0947
US

IV. Provider business mailing address

2709 POSITIVE CT
NORTH LAS VEGAS NV
89031-0947
US

V. Phone/Fax

Practice location:
  • Phone: 702-305-0652
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: CHRISTOPHER HANNIBLE
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 702-305-0652