=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962731174
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFE CHANGE INSTITUTE, LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/17/2009
-----------------------------------------------------
Last Update Date | 12/17/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9301 INDIAN SCHOOL RD NE STE 103
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87112-2861
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-280-5860
-----------------------------------------------------
Fax | 505-294-3904
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9301 INDIAN SCHOOL RD NE STE 103
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87112-2861
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-280-5860
-----------------------------------------------------
Fax | 505-294-3904
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER/OWNER
-----------------------------------------------------
Name | MRS. SHANNON ENRIGHT-SMITH
-----------------------------------------------------
Credential | LISW
-----------------------------------------------------
Telephone | 505-280-5860
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | I-06858
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------