Provider Demographics
NPI:1710753868
Name:CHANGE ACADEMY AT LAKE OF THE OZARKS
Entity Type:Organization
Organization Name:CHANGE ACADEMY AT LAKE OF THE OZARKS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF REVENUE CYCLE MANAGEMENT
Authorized Official - Prefix:MRS
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:
Mailing Address - Fax:
Practice Address - Street 1:4747 N 7TH ST STE 450
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-3851
Practice Address - Country:US
Practice Address - Phone:602-997-2880
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:2023-11-29
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)