Provider Demographics
NPI:1811620768
Name:EMPOWERED CHANGE COUNSELING SERVICE LCC
Entity Type:Organization
Organization Name:EMPOWERED CHANGE COUNSELING SERVICE LCC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:STONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-212-6929
Mailing Address - Street 1:3030 APPLE KNOLL LN
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45044-7991
Mailing Address - Country:US
Mailing Address - Phone:513-212-6929
Mailing Address - Fax:
Practice Address - Street 1:3030 APPLE KNOLL LN
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45044-7991
Practice Address - Country:US
Practice Address - Phone:513-212-6929
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-07
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1265086573Medicaid