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General NPI Number Information
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NPI Number | 1316203706
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Entity Type | Organization
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Legal Business Name | CHANGE INC
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Dates
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Enumeration Date | 04/10/2012
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Last Update Date | 05/13/2015
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Provider Practice Location Address
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Address Line | 1251 S MAIN ST
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City | MIDDLETOWN
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State | CT
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Zip | 06457-5050
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Country | US
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Telephone | 860-346-0771
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Fax | 860-346-0772
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Provider Business Mailing Address
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Address Line | 1251 S MAIN ST
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City | MIDDLETOWN
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State | CT
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Zip | 06457-5050
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Country | US
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Telephone | 860-346-0771
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Fax | 860-346-0772
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Authorized Official
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Title or Position | PRESIDENT / C.E.O.
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Name | MR. DERRICK CHRISTOPHER GIBBS JR.
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Credential |
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Telephone | 860-346-0771
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State | CT
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Taxonomy #3
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State | CT
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Taxonomy #4
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State | CT
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