Provider Demographics
NPI:1417630757
Name:CONSTRUCTIVE CHANGES LICENSED CLINICAL SOCIAL WORKER SERVICES
Entity Type:Organization
Organization Name:CONSTRUCTIVE CHANGES LICENSED CLINICAL SOCIAL WORKER SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:QUINTANILLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-615-0350
Mailing Address - Street 1:1717 W KIRBY AVE UNIT 306
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-5507
Mailing Address - Country:US
Mailing Address - Phone:217-615-0350
Mailing Address - Fax:
Practice Address - Street 1:44 E MAIN ST STE 406
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-3649
Practice Address - Country:US
Practice Address - Phone:217-615-0350
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health