Provider Demographics
NPI:1578960480
Name:CHANGES1, PLLC
Entity Type:Organization
Organization Name:CHANGES1, PLLC
Other - Org Name:CHANGES 1, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:NAOMI
Authorized Official - Middle Name:DIANA
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:313-695-3951
Mailing Address - Street 1:19940 CONANT
Mailing Address - Street 2:STE A, B, & C
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48234-1494
Mailing Address - Country:US
Mailing Address - Phone:313-305-4180
Mailing Address - Fax:313-733-8190
Practice Address - Street 1:19940 CONANT
Practice Address - Street 2:STE A, B, & C
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48234-1494
Practice Address - Country:US
Practice Address - Phone:313-305-4180
Practice Address - Fax:313-733-8190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-21
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM2800X
MISA0823228261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIF28207Medicare UPIN