Provider Demographics
NPI:1790039261
Name:CHANGE ACADEMY LAKE OF THE OZARKS
Entity Type:Organization
Organization Name:CHANGE ACADEMY LAKE OF THE OZARKS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:PAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-200-1608
Mailing Address - Street 1:130 CALO LN
Mailing Address - Street 2:
Mailing Address - City:LAKE OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65049-9208
Mailing Address - Country:US
Mailing Address - Phone:866-753-1373
Mailing Address - Fax:
Practice Address - Street 1:130 CALO LN
Practice Address - Street 2:
Practice Address - City:LAKE OZARK
Practice Address - State:MO
Practice Address - Zip Code:65049-9208
Practice Address - Country:US
Practice Address - Phone:866-753-1373
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-05
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012008387323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility