Provider Demographics
NPI:1114630076
Name:AVENUES FOR CHANGE
Entity Type:Organization
Organization Name:AVENUES FOR CHANGE
Other - Org Name:AVENUES FOR CHANGE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC-S, LCAC
Authorized Official - Phone:620-796-2206
Mailing Address - Street 1:PO BOX 1223
Mailing Address - Street 2:
Mailing Address - City:GREAT BEND
Mailing Address - State:KS
Mailing Address - Zip Code:67530-1223
Mailing Address - Country:US
Mailing Address - Phone:620-796-2206
Mailing Address - Fax:866-288-1782
Practice Address - Street 1:809 S PATTON RD
Practice Address - Street 2:
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530-4620
Practice Address - Country:US
Practice Address - Phone:620-796-2206
Practice Address - Fax:866-288-1782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-05
Last Update Date:2024-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty