Provider Demographics
NPI:1740409135
Name:LIFE CHANGE PSYCHOTHERAPY INSTITUTE, PC
Entity Type:Organization
Organization Name:LIFE CHANGE PSYCHOTHERAPY INSTITUTE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:F
Authorized Official - Last Name:MCKENNA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:505-271-5050
Mailing Address - Street 1:1200 EUBANK BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-5314
Mailing Address - Country:US
Mailing Address - Phone:505-271-5050
Mailing Address - Fax:505-271-1080
Practice Address - Street 1:1200 EUBANK BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-5314
Practice Address - Country:US
Practice Address - Phone:505-271-5050
Practice Address - Fax:505-271-1080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0892101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1194897108OtherINDIVIDUAL NPI