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General NPI Number Information
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NPI Number | 1497028161
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Entity Type | Organization
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Legal Business Name | ACTIVE CHANGE CENTER, LLC
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Dates
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Enumeration Date | 02/10/2012
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Last Update Date | 07/12/2022
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Provider Practice Location Address
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Address Line | 2498 N STOKESBERRY PL. SUITE 180
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City | MERIDIAN
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State | ID
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Zip | 83646
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Country | US
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Telephone | 208-403-7488
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Fax | 208-529-1960
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Provider Business Mailing Address
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Address Line | P.O. BOX 409
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City | MERIDIAN
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State | ID
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Zip | 83680-0409
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Country | US
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Telephone | 208-403-7488
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Fax | 208-529-1960
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Authorized Official
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Title or Position | BILLING AGENT
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Name | MR. DANNY LEE RASCO
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Credential |
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Telephone | 208-201-9513
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LCPC206
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License Number State | ID
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Taxonomy #3
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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