Provider Demographics
NPI:1164010369
Name:CHANGE DYNAMICS THERAPY
Entity Type:Organization
Organization Name:CHANGE DYNAMICS THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC-S
Authorized Official - Phone:859-582-9606
Mailing Address - Street 1:1004 EDGEWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40342-1641
Mailing Address - Country:US
Mailing Address - Phone:859-582-9606
Mailing Address - Fax:
Practice Address - Street 1:1004 EDGEWOOD WAY
Practice Address - Street 2:
Practice Address - City:LAWRENCEBURG
Practice Address - State:KY
Practice Address - Zip Code:40342-1641
Practice Address - Country:US
Practice Address - Phone:859-582-9606
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-04
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100537200Medicaid