Provider Demographics
NPI:1497028161
Name:ACTIVE CHANGE CENTER, LLC
Entity Type:Organization
Organization Name:ACTIVE CHANGE CENTER, LLC
Other - Org Name:ACTIVE CHANGE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING AGENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DANNY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:RASCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-201-9513
Mailing Address - Street 1:P.O. BOX 409
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83680-0409
Mailing Address - Country:US
Mailing Address - Phone:208-403-7488
Mailing Address - Fax:208-529-1960
Practice Address - Street 1:2498 N STOKESBERRY PL.
Practice Address - Street 2:SUITE 180
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646
Practice Address - Country:US
Practice Address - Phone:208-403-7488
Practice Address - Fax:208-529-1960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-10
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 101YP2500X
IDLCPC206101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty