Provider Demographics
NPI:1134696271
Name:CREATING CHANGE COACHING LLC
Entity Type:Organization
Organization Name:CREATING CHANGE COACHING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NODEREA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:347-742-5511
Mailing Address - Street 1:3205 HERING AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-5003
Mailing Address - Country:US
Mailing Address - Phone:347-742-5511
Mailing Address - Fax:
Practice Address - Street 1:3205 HERING AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469-5003
Practice Address - Country:US
Practice Address - Phone:347-742-5511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-26
Last Update Date:2018-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care