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General NPI Number Information
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NPI Number | 1366782427
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Entity Type | Organization
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Legal Business Name | CHANGE BEHAVIORAL HEALTH
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Dates
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Enumeration Date | 02/26/2013
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Last Update Date | 02/26/2013
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Provider Practice Location Address
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Address Line | 2315 FALLS AVE STE 1
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City | WATERLOO
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State | IA
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Zip | 50701-5736
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Country | US
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Telephone | 319-233-0323
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Fax | 319-233-5923
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Provider Business Mailing Address
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Address Line | 2315 FALLS AVE STE 1
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City | WATERLOO
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State | IA
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Zip | 50701-5736
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Country | US
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Telephone | 319-233-0323
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Fax | 319-233-5923
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MISS SHANNON LEE HARRINGTON
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Credential | BA,MA,MFT
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Telephone | 319-233-0323
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 007967
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License Number State | IA
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