MEDICARE: CHANGE ACADEMY AT LAKE OF THE OZARKS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1013635085
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHANGE ACADEMY AT LAKE OF THE OZARKS

Provider Business Mailing Address
First Line	:	5500 MING AVE STE 410
Second Line	:
City	:	BAKERSFIELD
State	:	CA
Zip	:	93309-4631
Country	:	US
Telephone Number	:	661-622-4132
Fax Number	:

Provider Business Practice Location Address
First Line	:	4800 SUGAR GROVE BLVD STE 275
Second Line	:
City	:	STAFFORD
State	:	TX
Zip	:	77477-2150
Country	:	US
Telephone Number	:	888-491-4177
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	SHARNELL SPENCER
Credential	:
Telephone Number	:	661-239-6923

Provider Enumeration Date	:	08/16/2022
Last Update Date	:	05/14/2025

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