Provider Demographics
NPI:1275102691
Name:EMPOWERING MINDS 4 CHANGE, LLC
Entity Type:Organization
Organization Name:EMPOWERING MINDS 4 CHANGE, LLC
Other - Org Name:EMPOWERING MINDS 4 CHANGE, LLC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BOARD CERTIFIED BEHAVIOR ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEMENTS
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA, LBA TLLP
Authorized Official - Phone:248-704-4751
Mailing Address - Street 1:4301 STRETTON FARM CT
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-5564
Mailing Address - Country:US
Mailing Address - Phone:571-580-9160
Mailing Address - Fax:
Practice Address - Street 1:4301 STRETTON FARM CT
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-5564
Practice Address - Country:US
Practice Address - Phone:571-580-9160
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-21
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty