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General NPI Number Information
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NPI Number | 1790039261
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Entity Type | Organization
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Legal Business Name | CHANGE ACADEMY LAKE OF THE OZARKS
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Dates
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Enumeration Date | 11/05/2012
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Last Update Date | 11/05/2012
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Provider Practice Location Address
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Address Line | 130 CALO LN
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City | LAKE OZARK
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State | MO
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Zip | 65049-9208
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Country | US
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Telephone | 866-753-1373
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Fax |
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Provider Business Mailing Address
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Address Line | 130 CALO LN
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City | LAKE OZARK
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State | MO
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Zip | 65049-9208
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Country | US
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Telephone | 866-753-1373
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Fax |
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Authorized Official
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Title or Position | THERAPIST
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Name | MRS. KIM PAGE
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Credential |
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Telephone | 573-200-1608
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 323P00000X
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Taxonomy Name | Psychiatric Residential Treatment Facility
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License Number | 2012008387
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License Number State | MO
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