Healthcare Provider Details

I. General information

NPI: 1821653239
Provider Name (Legal Business Name): THERAPEUTIC CHANGE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2019
Last Update Date: 05/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1314 KAUFFMAN AVE
VANCOUVER WA
98660-2725
US

IV. Provider business mailing address

1314 KAUFFMAN AVE
VANCOUVER WA
98660-2725
US

V. Phone/Fax

Practice location:
  • Phone: 360-602-1477
  • Fax: 360-334-5508
Mailing address:
  • Phone: 360-602-1477
  • Fax: 360-334-5508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SUMMER LYN BROWN
Title or Position: OWNER/ CLINICIAN
Credential: M.S.
Phone: 360-602-1477