Healthcare Provider Details

I. General information

NPI: 1487038006
Provider Name (Legal Business Name): CHANGES FOR LIFE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2015
Last Update Date: 05/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1086 S MAIN ST SUITE #2
ST GEORGE UT
84770-5277
US

IV. Provider business mailing address

1086 S MAIN ST SUITE #2
ST GEORGE UT
84770-5277
US

V. Phone/Fax

Practice location:
  • Phone: 435-218-2414
  • Fax:
Mailing address:
  • Phone: 435-218-2414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number6656303-6006
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number266415-3501
License Number StateUT

VIII. Authorized Official

Name: MARCIE D GRAY
Title or Position: OWNER/OPERATOR
Credential: LSUDC
Phone: 435-218-2414