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General NPI Number Information
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NPI Number | 1720540107
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Entity Type | Organization
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Legal Business Name | INDELIBLE CHANGES LLC
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Dates
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Enumeration Date | 04/03/2019
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Last Update Date | 12/14/2022
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Provider Practice Location Address
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Address Line | 12890 HARBOR DR
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City | WOODBRIDGE
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State | VA
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Zip | 22192-2921
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Country | US
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Telephone | 570-316-1020
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Fax |
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Provider Business Mailing Address
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Address Line | 4191 WATERWAY DR
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City | DUMFRIES
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State | VA
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Zip | 22025-1602
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Country | US
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Telephone | 703-474-0585
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MR. NICHOLAS ANTONIO WILLIAMS
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Credential | LPC
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Telephone | 703-474-0585
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #8
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #9
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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