Provider Demographics
NPI:1508311994
Name:CATALYST CENTER FOR CHANGE LLC
Entity Type:Organization
Organization Name:CATALYST CENTER FOR CHANGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:GRUPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-287-9500
Mailing Address - Street 1:4100 W. KENNEDY BLVD.
Mailing Address - Street 2:SUITE 210
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609
Mailing Address - Country:US
Mailing Address - Phone:813-287-9500
Mailing Address - Fax:813-336-5226
Practice Address - Street 1:4100 W KENNEDY BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-2288
Practice Address - Country:US
Practice Address - Phone:813-287-9500
Practice Address - Fax:813-336-5226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-16
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH14171101YM0800X
FLSW99921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty