Healthcare Provider Details

I. General information

NPI: 1871180752
Provider Name (Legal Business Name): CATALYST FOR CHANGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2020
Last Update Date: 04/12/2021
Certification Date: 04/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5151 MONROE ST STE 200
TOLEDO OH
43623-3466
US

IV. Provider business mailing address

6923 HEATHER COVE PL
MAUMEE OH
43537-1062
US

V. Phone/Fax

Practice location:
  • Phone: 567-455-1401
  • Fax:
Mailing address:
  • Phone: 419-270-0521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: KESHA JACKSON
Title or Position: SOCIAL WORKER/MH CLINICIAN
Credential: MSW, LSW
Phone: 419-807-8185