=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598930216
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE HOUSE OF CHANGE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2008
-----------------------------------------------------
Last Update Date | 04/23/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 41335 N ARBOR AVE
-----------------------------------------------------
City | QUEEN CREEK
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85240-6120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-560-6460
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 41335 N ARBOR AVE
-----------------------------------------------------
City | QUEEN CREEK
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85240-6120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-560-6460
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MARIA ANDERSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 480-560-6460
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number | BH3020
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------