Provider Demographics
NPI:1316203706
Name:CHANGE INC
Entity Type:Organization
Organization Name:CHANGE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / C.E.O.
Authorized Official - Prefix:MR
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:GIBBS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:860-346-0771
Mailing Address - Street 1:1251 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-5050
Mailing Address - Country:US
Mailing Address - Phone:860-346-0771
Mailing Address - Fax:860-346-0772
Practice Address - Street 1:1251 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-5050
Practice Address - Country:US
Practice Address - Phone:860-346-0771
Practice Address - Fax:860-346-0772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-10
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT101YP2500X, 1041C0700X, 251B00000X
305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251B00000XAgenciesCase ManagementGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No305R00000XManaged Care OrganizationsPreferred Provider Organization