Healthcare Provider Details

I. General information

NPI: 1487977583
Provider Name (Legal Business Name): CHANGING HOW I LIVE LIFE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2010
Last Update Date: 09/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1006 E YAGER LN A 104
AUSTIN TX
78753-7088
US

IV. Provider business mailing address

1006 E. YAGER LANE A 104
AUSTIN TX
78753
US

V. Phone/Fax

Practice location:
  • Phone: 512-385-4799
  • Fax:
Mailing address:
  • Phone: 512-385-4799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number5006
License Number StateTX

VIII. Authorized Official

Name: MISS LORI D. WILSON
Title or Position: EXECUTIVE DIRECTOR
Credential: LCDC
Phone: 512-385-4799