{
"Npi": {
"NPI": "1497028161",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "ACTIVE CHANGE CENTER, LLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "P.O. BOX 409",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "MERIDIAN",
"MailingAddressStateName": "ID",
"MailingAddressPostalCode": "83680-0409",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "208-403-7488",
"MailingAddressFaxNumber": "208-529-1960",
"FirstLinePracticeLocationAddress": "2498 N STOKESBERRY PL.",
"SecondLinePracticeLocationAddress": "SUITE 180",
"PracticeLocationAddressCityName": "MERIDIAN",
"PracticeLocationAddressStateName": "ID",
"PracticeLocationAddressPostalCode": "83646",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "208-403-7488",
"PracticeLocationAddressFaxNumber": "208-529-1960",
"EnumerationDate": "02/10/2012",
"LastUpdateDate": "07/12/2022",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "RASCO",
"AuthorizedOfficialFirstName": "DANNY",
"AuthorizedOfficialMiddleName": "LEE",
"AuthorizedOfficialTitle": "BILLING AGENT",
"AuthorizedOfficialNamePrefix": "MR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "208-201-9513",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "101YM0800X",
"TaxonomyName": "Mental Health Counselor",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "101YP2500X",
"TaxonomyName": "Professional Counselor",
"LicenseNumber": "LCPC206",
"LicenseNumberStateCode": "ID",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "101YP2500X",
"TaxonomyName": "Professional Counselor",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": [
{
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
]
}
}
}