Healthcare Provider Details

I. General information

NPI: 1083317366
Provider Name (Legal Business Name): CHANGE AND EVOLVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2023
Last Update Date: 05/18/2023
Certification Date: 05/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14634 DIANE MANOR LN
HUMBLE TX
77396-4560
US

IV. Provider business mailing address

PO BOX 273
HUMBLE TX
77347-0273
US

V. Phone/Fax

Practice location:
  • Phone: 702-466-4841
  • Fax:
Mailing address:
  • Phone: 702-466-4841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: CASSANDRA BLACK
Title or Position: CEO
Credential:
Phone: 702-466-4841