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General NPI Number Information
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NPI Number | 1669778866
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Entity Type | Organization
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Legal Business Name | CENTER FOR LIFESTYLE CHANGE
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Dates
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Enumeration Date | 02/04/2011
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Last Update Date | 02/04/2011
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Provider Practice Location Address
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Address Line | 684 VALLEY DR
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City | VALPARAISO
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State | IN
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Zip | 46383-8912
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Country | US
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Telephone | 219-395-6637
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Fax | 219-465-0784
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Provider Business Mailing Address
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Address Line | PO BOX 1921
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City | VALPARAISO
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State | IN
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Zip | 46384-1921
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Country | US
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Telephone | 219-395-6637
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Fax | 219-465-0784
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Authorized Official
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Title or Position | OWNER
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Name | MS. CAROLYN S LOHSE
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Credential | LSCW
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Telephone | 219-395-6637
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 34001814A
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License Number State | IN
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