Provider Demographics
NPI:1093892671
Name:CATALYST FOR CHANGE LLC
Entity Type:Organization
Organization Name:CATALYST FOR CHANGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER REGISTERED AGEWNT
Authorized Official - Prefix:
Authorized Official - First Name:SAMIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HUSNI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:407-968-6723
Mailing Address - Street 1:4114 SHADE TREE LOOP
Mailing Address - Street 2:STE 90
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32810
Mailing Address - Country:US
Mailing Address - Phone:407-968-6723
Mailing Address - Fax:407-294-4332
Practice Address - Street 1:2101 PARK CENTER DRIVE
Practice Address - Street 2:SUITE 270
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835
Practice Address - Country:US
Practice Address - Phone:407-523-1213
Practice Address - Fax:407-523-2398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5826103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL21491OtherBCBS GROUP
FL51415OtherBCBS
FL21491OtherBCBS GROUP