Provider Demographics
NPI:1679741144
Name:CENTER OF CHANGE
Entity Type:Organization
Organization Name:CENTER OF CHANGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKENNA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:417-888-0886
Mailing Address - Street 1:1615A S INGRAM MILL RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-2261
Mailing Address - Country:US
Mailing Address - Phone:417-888-0886
Mailing Address - Fax:417-888-0846
Practice Address - Street 1:1615A S INGRAM MILL RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2261
Practice Address - Country:US
Practice Address - Phone:417-888-0886
Practice Address - Fax:417-888-0846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-18
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOPY01825103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO508440609Medicaid
MO508440609Medicaid