Provider Demographics
NPI:1730656000
Name:EMBODIED CHANGE, INC
Entity Type:Organization
Organization Name:EMBODIED CHANGE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOLLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:RYAN STOCK
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:773-726-7290
Mailing Address - Street 1:5255 W ARDMORE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-6520
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4055 W PETERSON AVE STE 104
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-6183
Practice Address - Country:US
Practice Address - Phone:773-726-7290
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-25
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1316219892Medicaid
=========OtherBEHAVIORAL HEALTH