Healthcare Provider Details

I. General information

NPI: 1760387815
Provider Name (Legal Business Name): CHANGE REACTION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2026
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3094 W MARKET ST STE 103
FAIRLAWN OH
44333-3617
US

IV. Provider business mailing address

3094 W MARKET ST STE 103
FAIRLAWN OH
44333-3617
US

V. Phone/Fax

Practice location:
  • Phone: 234-706-2058
  • Fax: 234-706-2059
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: KIMBERLY GREEN
Title or Position: CEO
Credential:
Phone: 240-432-7659