=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033267232
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHANGE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 227 COLFAX AVE N SUITE 130
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55405-1419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-759-8789
-----------------------------------------------------
Fax | 612-823-3869
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 227 COLFAX AVE N SUITE 130
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55405-1419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-759-8789
-----------------------------------------------------
Fax | 612-823-3869
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRINCIPAL
-----------------------------------------------------
Name | DR. JAMES A NELSON
-----------------------------------------------------
Credential | PH.D., LMFT
-----------------------------------------------------
Telephone | 612-759-8789
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 519
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------