Provider Demographics
NPI:1568821346
Name:CHANGEPOINT INTEGRATED HEALTH
Entity Type:Organization
Organization Name:CHANGEPOINT INTEGRATED HEALTH
Other - Org Name:WOODLAND HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTRACTING AND CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOSPODKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-537-2951
Mailing Address - Street 1:1801 W DEUCE OF CLUBS STE 100
Mailing Address - Street 2:
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901-2704
Mailing Address - Country:US
Mailing Address - Phone:928-537-2951
Mailing Address - Fax:928-892-5828
Practice Address - Street 1:447 S WOODLAND LN
Practice Address - Street 2:
Practice Address - City:PINETOP
Practice Address - State:AZ
Practice Address - Zip Code:85935-7139
Practice Address - Country:US
Practice Address - Phone:928-537-2951
Practice Address - Fax:928-892-5828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-22
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH4759323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ117138Medicaid