Provider Demographics
NPI:1114560257
Name:COURAGE FOR CHANGE, LLC
Entity Type:Organization
Organization Name:COURAGE FOR CHANGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GABRIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:AVITABILE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:201-218-2452
Mailing Address - Street 1:189 ELIZABETH ST
Mailing Address - Street 2:
Mailing Address - City:ORADELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07649-2608
Mailing Address - Country:US
Mailing Address - Phone:201-218-2452
Mailing Address - Fax:
Practice Address - Street 1:297 KINDERKAMACK RD STE 212
Practice Address - Street 2:
Practice Address - City:ORADELL
Practice Address - State:NJ
Practice Address - Zip Code:07649-1535
Practice Address - Country:US
Practice Address - Phone:201-218-2452
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-22
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health