Provider Demographics
NPI:1275118036
Name:CONSCIOUS CHANGE LLC
Entity Type:Organization
Organization Name:CONSCIOUS CHANGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISNA
Authorized Official - Middle Name:
Authorized Official - Last Name:HERVEY
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:662-638-3388
Mailing Address - Street 1:PO BOX 2969
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-3001
Mailing Address - Country:US
Mailing Address - Phone:662-638-3388
Mailing Address - Fax:844-728-9613
Practice Address - Street 1:507 HERITAGE DR STE 101
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5571
Practice Address - Country:US
Practice Address - Phone:662-638-3388
Practice Address - Fax:844-728-9613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-12
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07784361Medicaid