{
"Npi": {
"NPI": "1619533916",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "CREATE CHANGE WELLNESS CENTER LLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "50 E 37TH ST",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "PATERSON",
"MailingAddressStateName": "NJ",
"MailingAddressPostalCode": "07514-1212",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "973-567-5941",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "50 E 37TH ST",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "PATERSON",
"PracticeLocationAddressStateName": "NJ",
"PracticeLocationAddressPostalCode": "07514-1212",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "973-567-5941",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "05/13/2019",
"LastUpdateDate": "05/13/2019",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "DUSSARD",
"AuthorizedOfficialFirstName": "CYRENA",
"AuthorizedOfficialMiddleName": "M",
"AuthorizedOfficialTitle": "CLINICAL DIRECTOR",
"AuthorizedOfficialNamePrefix": "MRS.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "MSW, LSW",
"AuthorizedOfficialTelephoneNumber": "973-567-5941",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "101Y00000X",
"TaxonomyName": "Counselor",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "104100000X",
"TaxonomyName": "Social Worker",
"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": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
]
}
}
}