Provider Demographics
NPI:1407153885
Name:AGENCY OF CHANGE
Entity Type:Organization
Organization Name:AGENCY OF CHANGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DONOHUE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:954-465-5142
Mailing Address - Street 1:900 NE 18TH AVE
Mailing Address - Street 2:1207
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-3063
Mailing Address - Country:US
Mailing Address - Phone:954-524-6861
Mailing Address - Fax:
Practice Address - Street 1:900 NE 18TH AVE
Practice Address - Street 2:1207
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304-3063
Practice Address - Country:US
Practice Address - Phone:954-524-6861
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-20
Last Update Date:2011-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW83271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty