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General NPI Number Information
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NPI Number | 1467931022
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Entity Type | Organization
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Legal Business Name | CHANGE BY CONIAH FAMILY COUNSELING, A PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 08/14/2018
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Last Update Date | 08/14/2018
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Provider Practice Location Address
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Address Line | 2376 MARITIME DR STE 200
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City | ELK GROVE
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State | CA
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Zip | 95758-3640
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Country | US
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Telephone | 916-531-5647
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Fax | 916-405-3470
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Provider Business Mailing Address
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Address Line | 2376 MARITIME DR STE 200
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City | ELK GROVE
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State | CA
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Zip | 95758-3640
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Country | US
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Telephone | 916-531-5647
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Fax | 916-531-5647
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Authorized Official
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Title or Position | CEO
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Name | MRS. CAROL LETRESSE WALLACE
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Credential | LMFT
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Telephone | 916-531-5647
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | LMFT48746
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License Number State | CA
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