Healthcare Provider Details

I. General information

NPI: 1942129952
Provider Name (Legal Business Name): CHANGES FOR LIFE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4580 SUNRISE HWY UNIT 3
OAKDALE NY
11769-1000
US

IV. Provider business mailing address

4580 SUNRISE HWY UNIT 3
OAKDALE NY
11769-1000
US

V. Phone/Fax

Practice location:
  • Phone: 631-312-3350
  • Fax:
Mailing address:
  • Phone: 631-312-3350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code224Y00000X
TaxonomyClinical Exercise Physiologist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: THERESA CORDOVA
Title or Position: OWNER/PRESIDENT
Credential:
Phone: 631-312-3350