Provider Demographics
NPI:1326091844
Name:CHANGEWORKS PSYCHOTHERAPY & LIFE COACHING SERVICES, LLC
Entity Type:Organization
Organization Name:CHANGEWORKS PSYCHOTHERAPY & LIFE COACHING SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:
Authorized Official - Last Name:FANNIN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:703-626-0381
Mailing Address - Street 1:9218 CENTREVILLE RD
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-5131
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9218 CENTREVILLE RD
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-5131
Practice Address - Country:US
Practice Address - Phone:703-626-0381
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040047081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA10141788Medicaid