Provider Demographics
NPI:1003207002
Name:CHANGE WITHIN REACH, LICENSED CLINICAL SOCIAL WORKER CORPORATION
Entity Type:Organization
Organization Name:CHANGE WITHIN REACH, LICENSED CLINICAL SOCIAL WORKER CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:GERSHELIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-445-2266
Mailing Address - Street 1:17777 VENTURA BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-3738
Mailing Address - Country:US
Mailing Address - Phone:213-445-2266
Mailing Address - Fax:213-908-1233
Practice Address - Street 1:17777 VENTURA BLVD STE 105
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316
Practice Address - Country:US
Practice Address - Phone:213-445-2266
Practice Address - Fax:213-908-1233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-11
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW28777261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1285901942Medicaid