Provider Demographics
NPI:1598381030
Name:THERAPEUTIC CENTER FOR CHANGE
Entity Type:Organization
Organization Name:THERAPEUTIC CENTER FOR CHANGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:GILLIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SQUILLACIOTI
Authorized Official - Suffix:
Authorized Official - Credentials:LCMHC
Authorized Official - Phone:704-755-5213
Mailing Address - Street 1:5132 NEWPORT LANDING WAY
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28056-8521
Mailing Address - Country:US
Mailing Address - Phone:631-974-9403
Mailing Address - Fax:
Practice Address - Street 1:1566 UNION RD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-5301
Practice Address - Country:US
Practice Address - Phone:704-755-5213
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-21
Last Update Date:2020-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty