Provider Demographics
NPI:1801201330
Name:TIME FOR A CHANGE MINISTRY
Entity Type:Organization
Organization Name:TIME FOR A CHANGE MINISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LOU
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLIDAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-818-5091
Mailing Address - Street 1:880 HANCOCK AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06605-1930
Mailing Address - Country:US
Mailing Address - Phone:203-818-5091
Mailing Address - Fax:203-923-8472
Practice Address - Street 1:880 HANCOCK AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06605-1930
Practice Address - Country:US
Practice Address - Phone:203-818-5091
Practice Address - Fax:203-923-8472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-23
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT17053333309021324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility