Provider Demographics
NPI:1467931022
Name:CHANGE BY CONIAH FAMILY COUNSELING, A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:CHANGE BY CONIAH FAMILY COUNSELING, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:LETRESSE
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:916-531-5647
Mailing Address - Street 1:2376 MARITIME DR STE 200
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-3640
Mailing Address - Country:US
Mailing Address - Phone:916-531-5647
Mailing Address - Fax:916-531-5647
Practice Address - Street 1:2376 MARITIME DR STE 200
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-3640
Practice Address - Country:US
Practice Address - Phone:916-531-5647
Practice Address - Fax:916-405-3470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT48746106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty