Provider Demographics
NPI:1790159598
Name:THE LIFE CHANGE GROUP
Entity Type:Organization
Organization Name:THE LIFE CHANGE GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:M
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:PH D
Authorized Official - Phone:770-486-4887
Mailing Address - Street 1:590 WENTWORTH CT
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30215-7830
Mailing Address - Country:US
Mailing Address - Phone:404-664-5797
Mailing Address - Fax:
Practice Address - Street 1:302 STEVENS ENTRY
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-1325
Practice Address - Country:US
Practice Address - Phone:770-486-4887
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-18
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003202103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty