Healthcare Provider Details

I. General information

NPI: 1164986121
Provider Name (Legal Business Name): CONDITIONS FOR CHANGE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2019
Last Update Date: 11/10/2022
Certification Date: 11/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 BROOK CIR
GLENMOORE PA
19343-1204
US

IV. Provider business mailing address

35 BROOK CIR
GLENMOORE PA
19343-1204
US

V. Phone/Fax

Practice location:
  • Phone: 610-427-0698
  • Fax:
Mailing address:
  • Phone: 610-427-0698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name: MS. JENNIFER LEE ERICKSON
Title or Position: OWNER
Credential: LPC
Phone: 610-427-0698