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General NPI Number Information
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NPI Number | 1578134268
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Entity Type | Organization
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Legal Business Name | OPTIMAL CHANGE, LLC
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Dates
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Enumeration Date | 07/05/2021
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Last Update Date | 07/05/2021
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Provider Practice Location Address
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Address Line | 2001 MAINE ST. SUITE 102
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City | QUINCY
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State | IL
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Zip | 62301-4345
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Country | US
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Telephone | 217-740-2719
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Fax | 217-214-8005
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Provider Business Mailing Address
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Address Line | 2001 MAINE ST. SUITE 102
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City | QUINCY
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State | IL
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Zip | 62301-4345
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Country | US
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Telephone | 217-740-2719
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Fax | 217-214-8005
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Authorized Official
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Title or Position | BEHAVIORAL HEALTH THERAPIST
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Name | KETTISHA HODGES
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Credential | LCSW
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Telephone | 573-406-2473
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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