Provider Demographics
NPI:1659900835
Name:CHANGE ACADEMY AT LAKE OF THE OZARKS
Entity Type:Organization
Organization Name:CHANGE ACADEMY AT LAKE OF THE OZARKS
Other - Org Name:POTOMAC AT HOBBLE CREEK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF REVENUE CYCLE MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:J
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:661-829-4060
Mailing Address - Street 1:5500 MING AVE STE 410
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93309-4631
Mailing Address - Country:US
Mailing Address - Phone:661-622-4132
Mailing Address - Fax:
Practice Address - Street 1:266 SOUTH LEFT FORK HOBBLE CREEK CANYON ROAD
Practice Address - Street 2:
Practice Address - City:SPRINGVILLE
Practice Address - State:UT
Practice Address - Zip Code:84663
Practice Address - Country:US
Practice Address - Phone:866-534-7057
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHANGE ACADEMY AT LAKE OF THE OZARKS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-04-08
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children