=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659517472
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHANGE YOUR MIND, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/29/2008
-----------------------------------------------------
Last Update Date | 12/29/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 210 W FRONT ST STE 208
-----------------------------------------------------
City | RED BANK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07701-1171
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-996-4829
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 113 CENTRAL AVE
-----------------------------------------------------
City | OCEAN GROVE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07756-1101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-775-1381
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. FAYE ELLEN SCHOLZ
-----------------------------------------------------
Credential | MSW, LCSW, LCADC
-----------------------------------------------------
Telephone | 732-775-1381
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 44SC05231700
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------