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General NPI Number Information
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NPI Number | 1538995071
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Entity Type | Organization
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Legal Business Name | CHANGE ACADEMY AT LAKE OF THE OZARKS
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Dates
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Enumeration Date | 09/11/2024
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Last Update Date | 05/21/2025
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Provider Practice Location Address
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Address Line | 5470 KIETZKE LN STE 300
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City | RENO
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State | NV
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Zip | 89511-2099
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Country | US
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Telephone | 480-550-9281
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Fax |
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Provider Business Mailing Address
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Address Line | 5500 MING AVE STE 410
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City | BAKERSFIELD
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State | CA
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Zip | 93309-4631
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING MANAGER
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Name | SHARNELL SPENCER
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Credential |
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Telephone | 661-239-6923
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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