Provider Demographics
NPI:1043516727
Name:CHANGING DYNAMICS-CHANGING LIVES, LLC
Entity Type:Organization
Organization Name:CHANGING DYNAMICS-CHANGING LIVES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:L
Authorized Official - Last Name:SIMMS
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC, CSAC
Authorized Official - Phone:540-270-8189
Mailing Address - Street 1:706 W BROOKLAND PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23222-2515
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:706 W BROOKLAND PARK BLVD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23222-2515
Practice Address - Country:US
Practice Address - Phone:540-455-2191
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-28
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0710102319101YA0400X
VA07011004763101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty