Provider Demographics
NPI:1407210867
Name:CREATE CHANGE, LLC
Entity Type:Organization
Organization Name:CREATE CHANGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALTY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:503-842-7855
Mailing Address - Street 1:312 NW 10TH AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-3121
Mailing Address - Country:US
Mailing Address - Phone:503-842-7855
Mailing Address - Fax:503-222-0984
Practice Address - Street 1:312 NW 10TH AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-3121
Practice Address - Country:US
Practice Address - Phone:503-842-7855
Practice Address - Fax:503-222-0984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-11
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR137445Medicare PIN