Provider Demographics
NPI:1164111803
Name:SEA CHANGE PSYCHOTHERAPY, LLC
Entity Type:Organization
Organization Name:SEA CHANGE PSYCHOTHERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:MADSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPC
Authorized Official - Phone:404-448-2080
Mailing Address - Street 1:3681 DEVENWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519
Mailing Address - Country:US
Mailing Address - Phone:913-235-2345
Mailing Address - Fax:
Practice Address - Street 1:32 LENOX POINTE NE SUITE B
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30324
Practice Address - Country:US
Practice Address - Phone:404-448-2080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-08
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1760027932OtherNPPES