Healthcare Provider Details

I. General information

NPI: 1275175861
Provider Name (Legal Business Name): A CHANGE IN LIFE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2019
Last Update Date: 10/01/2021
Certification Date: 10/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 FITZHUGH AVE STE 205
RICHMOND VA
23230-3531
US

IV. Provider business mailing address

4901 FITZHUGH AVE STE 205
RICHMOND VA
23230-3531
US

V. Phone/Fax

Practice location:
  • Phone: 804-716-5960
  • Fax: 804-997-7907
Mailing address:
  • Phone: 804-716-5960
  • Fax: 804-997-7907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: KEITH LAMONT SHELTON
Title or Position: OWNER/CEO
Credential:
Phone: 804-716-1560