Provider Demographics
NPI:1043969173
Name:SEA CHANGE, LLC
Entity Type:Organization
Organization Name:SEA CHANGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:POPKEY
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC, CEDS, SEP
Authorized Official - Phone:480-390-1409
Mailing Address - Street 1:8160 E BUTHERUS DR STE 5
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-2523
Mailing Address - Country:US
Mailing Address - Phone:480-390-1409
Mailing Address - Fax:480-383-6825
Practice Address - Street 1:8160 E BUTHERUS DR STE 5
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-2523
Practice Address - Country:US
Practice Address - Phone:480-390-1409
Practice Address - Fax:480-383-6825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-23
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ884628Medicaid