Healthcare Provider Details

I. General information

NPI: 1326559154
Provider Name (Legal Business Name): CHANGE LIVES THROUGH EDUCATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2017
Last Update Date: 10/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4680 MERCHANTS PARK CIR STE 214
COLLIERVILLE TN
38017-9132
US

IV. Provider business mailing address

7756 ANTIGUA CV
MEMPHIS TN
38119-9154
US

V. Phone/Fax

Practice location:
  • Phone: 901-620-2150
  • Fax:
Mailing address:
  • Phone: 901-212-1950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MS. SHERVELLE DEMETRIA THOMAS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 901-620-2150