Provider Demographics
NPI:1417028374
Name:CENTER OF CHANGE
Entity Type:Organization
Organization Name:CENTER OF CHANGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:JENERETTE
Authorized Official - Last Name:HORNSBY
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LBSW
Authorized Official - Phone:803-432-5200
Mailing Address - Street 1:2039 W DEKALB ST
Mailing Address - Street 2:BUILDING 1, SUITE 2
Mailing Address - City:CAMDEN
Mailing Address - State:SC
Mailing Address - Zip Code:29020-2092
Mailing Address - Country:US
Mailing Address - Phone:803-432-5200
Mailing Address - Fax:803-432-5199
Practice Address - Street 1:2039 W DEKALB ST
Practice Address - Street 2:BUILDING 1, SUITE 2
Practice Address - City:CAMDEN
Practice Address - State:SC
Practice Address - Zip Code:29020-2092
Practice Address - Country:US
Practice Address - Phone:803-432-5200
Practice Address - Fax:803-432-5199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC87241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4217Medicaid