=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366808834
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHANGE THERAPY CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2016
-----------------------------------------------------
Last Update Date | 01/13/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 954 EASTPORT CENTRE DR SUITE B
-----------------------------------------------------
City | VALPARAISO
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46383-4457
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-338-6844
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 954 EASTPORT CENTRE DR SUITE B
-----------------------------------------------------
City | VALPARAISO
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46383-4457
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MELISSA SCANNELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 847-338-6844
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------