Provider Demographics
NPI:1598121261
Name:CHANGE OF LIFE LLC
Entity Type:Organization
Organization Name:CHANGE OF LIFE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:D
Authorized Official - Last Name:NEWCOMER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:816-529-5990
Mailing Address - Street 1:4602 NE 83RD TER
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64119-7617
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7280 NW 87TH TER
Practice Address - Street 2:STE 210
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64153-3720
Practice Address - Country:US
Practice Address - Phone:816-529-5990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-11
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty