Provider Demographics
NPI:1760050033
Name:WAVES OF CHANGE COUNSELING GROUP LLC
Entity Type:Organization
Organization Name:WAVES OF CHANGE COUNSELING GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:J
Authorized Official - Last Name:OTT
Authorized Official - Suffix:
Authorized Official - Credentials:LADC-1, LCSW
Authorized Official - Phone:781-816-8281
Mailing Address - Street 1:475 HILLSIDE AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02494-1200
Mailing Address - Country:US
Mailing Address - Phone:781-816-8218
Mailing Address - Fax:
Practice Address - Street 1:475 HILLSIDE AVE STE 2
Practice Address - Street 2:
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02494-1200
Practice Address - Country:US
Practice Address - Phone:781-816-8218
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA18460OtherCOMMERICAL HEALTH INSURANCE