Provider Demographics
NPI:1821752833
Name:CLUSTER OF LIFE CHANGES LLC
Entity Type:Organization
Organization Name:CLUSTER OF LIFE CHANGES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:CARNESHA
Authorized Official - Middle Name:L
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:254-289-2285
Mailing Address - Street 1:2001 STERLING TRACE DR
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-9740
Mailing Address - Country:US
Mailing Address - Phone:254-289-2285
Mailing Address - Fax:682-593-3936
Practice Address - Street 1:300 N RUFE SNOW DR
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-4235
Practice Address - Country:US
Practice Address - Phone:254-289-2285
Practice Address - Fax:682-593-3936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-26
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1306405592OtherINDIVIDUAL TYPE I NPI