Provider Demographics
NPI:1629570544
Name:TRUE CHANGES BEHAVIOR THERAPY, LLC
Entity Type:Organization
Organization Name:TRUE CHANGES BEHAVIOR THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARYVONNE
Authorized Official - Middle Name:C
Authorized Official - Last Name:CARDELL
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA, LBA
Authorized Official - Phone:718-986-3163
Mailing Address - Street 1:41 KOSCIUSZKO ST APT 312
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11205-4986
Mailing Address - Country:US
Mailing Address - Phone:718-986-3163
Mailing Address - Fax:718-228-9216
Practice Address - Street 1:41 KOSCIUSZKO ST APT 312
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11205-4986
Practice Address - Country:US
Practice Address - Phone:718-986-3163
Practice Address - Fax:718-228-9216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-07
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001310103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY001310OtherNEW YORK STATE
1-15-19493OtherBACB