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General NPI Number Information
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NPI Number | 1760914931
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Entity Type | Organization
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Legal Business Name | CHANGE & GROWTH THERAPY CENTER
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Dates
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Enumeration Date | 03/28/2017
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Last Update Date | 03/28/2017
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Provider Practice Location Address
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Address Line | 8401 LAKE WORTH RD STE. 202
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City | LAKE WORTH
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State | FL
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Zip | 33467-2400
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Country | US
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Telephone | 561-635-2431
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Fax |
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Provider Business Mailing Address
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Address Line | 8401 LAKE WORTH RD STE. 202
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City | LAKE WORTH
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State | FL
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Zip | 33467-2400
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MS. MAYRA BAGNOLI
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Credential |
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Telephone | 561-635-2341
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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 | SW12223
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License Number State | FL
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