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General NPI Number Information
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NPI Number | 1245199975
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Entity Type | Organization
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Legal Business Name | CHANGE OF LIFE
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Dates
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Enumeration Date | 01/19/2026
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Last Update Date | 01/19/2026
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Provider Practice Location Address
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Address Line | 411 ROOSEVELT ST
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City | INDIANOLA
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State | MS
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Zip | 38751-3141
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Country | US
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Telephone | 662-635-9972
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Fax | 662-452-5066
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Provider Business Mailing Address
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Address Line | 411 ROOSEVELT ST
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City | INDIANOLA
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State | MS
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Zip | 38751-3141
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Country | US
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Telephone | 662-635-0794
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Fax | 662-452-5066
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Authorized Official
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Title or Position | CEO
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Name | PAMELA LORRAINE RANDLE
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Credential |
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Telephone | 662-207-3645
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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