Provider Demographics
NPI:1073666244
Name:CENTER FOR MARRIAGE AND FAMILY THERAPY, LLC
Entity Type:Organization
Organization Name:CENTER FOR MARRIAGE AND FAMILY THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LMFT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:VICKERS
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:256-881-5352
Mailing Address - Street 1:116 LILY FLAGG RD SW
Mailing Address - Street 2:SUITE D
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35802-3066
Mailing Address - Country:US
Mailing Address - Phone:256-881-5352
Mailing Address - Fax:256-881-5355
Practice Address - Street 1:116 LILY FLAGG ROAD
Practice Address - Street 2:SUITE D
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35802-3066
Practice Address - Country:US
Practice Address - Phone:256-881-5352
Practice Address - Fax:256-881-5355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 106H00000X
ALL116101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALLMFT330OtherBEHAVIORAL HEALTH COUNSELOR