Healthcare Provider Details

I. General information

NPI: 1568094225
Provider Name (Legal Business Name): A CHANCE FOR CHANGE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2020
Last Update Date: 08/03/2020
Certification Date: 08/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 WATERSIDE DR STE 2525
NORFOLK VA
23510-3316
US

IV. Provider business mailing address

999 WATERSIDE DR STE 2525
NORFOLK VA
23510-3316
US

V. Phone/Fax

Practice location:
  • Phone: 757-777-3454
  • Fax: 757-568-7437
Mailing address:
  • Phone: 757-777-3454
  • Fax: 757-568-7437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License Number
License Number State

VIII. Authorized Official

Name: MS. AMANDA COLEMON
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: BA, PSYCHOLOGY, QMHP
Phone: 980-745-9867