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General NPI Number Information
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NPI Number | 1881152817
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Entity Type | Organization
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Legal Business Name | CHANGE YOUR REALITY
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Dates
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Enumeration Date | 03/08/2019
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Last Update Date | 03/08/2019
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Provider Practice Location Address
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Address Line | 729 TRUE ST APT 3
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City | COLUMBIA
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State | SC
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Zip | 29209-1659
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Country | US
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Telephone | 803-530-0510
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Fax |
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Provider Business Mailing Address
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Address Line | 729 TRUE ST APT 3
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City | COLUMBIA
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State | SC
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Zip | 29209-1659
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Country | US
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Telephone | 803-530-0510
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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. RICHARD ALAN WADE
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Credential | THERAPIST
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Telephone | 803-530-0510
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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 | 251B00000X
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Taxonomy Name | Case Management Agency
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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 | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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