=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073871919
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TIME TO CHANGE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/29/2012
-----------------------------------------------------
Last Update Date | 04/29/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 102 WICKER ST
-----------------------------------------------------
City | SANFORD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27330-4252
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-777-9025
-----------------------------------------------------
Fax | 919-777-9026
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 102 WICKER ST
-----------------------------------------------------
City | SANFORD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27330-4252
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-777-9025
-----------------------------------------------------
Fax | 919-777-9026
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | CAROLYN ALLEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-925-5747
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------