=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346633955
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TIME TO CHANGE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2015
-----------------------------------------------------
Last Update Date | 03/07/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8609 LYNDALE AVE S #110
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55420-2754
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-358-1009
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8609 LYNDALE AVE S #110, #214, #215
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55420-2754
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-358-1009
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | ALLEN JEROME JOHNSON
-----------------------------------------------------
Credential | MA LADC
-----------------------------------------------------
Telephone | 952-484-5401
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 1076645-1-CDT
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------