Provider Demographics
NPI:1386019727
Name:A CHANGE INTO RECOVERY, LLC
Entity Type:Organization
Organization Name:A CHANGE INTO RECOVERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:CDP, NCAC
Authorized Official - Phone:253-841-8165
Mailing Address - Street 1:719 E MAIN
Mailing Address - Street 2:SUITE C
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-3306
Mailing Address - Country:US
Mailing Address - Phone:253-841-8165
Mailing Address - Fax:253-841-8168
Practice Address - Street 1:719 E MAIN
Practice Address - Street 2:SUITE C
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3306
Practice Address - Country:US
Practice Address - Phone:253-841-8165
Practice Address - Fax:253-841-8168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-10
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00002706251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health