Provider Demographics
NPI:1831490887
Name:EFFECTIVE CHANGE LLC
Entity Type:Organization
Organization Name:EFFECTIVE CHANGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:BRITTAIN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:808-934-7566
Mailing Address - Street 1:PO BOX 1038
Mailing Address - Street 2:
Mailing Address - City:KURTISTOWN
Mailing Address - State:HI
Mailing Address - Zip Code:96760-1038
Mailing Address - Country:US
Mailing Address - Phone:808-934-7566
Mailing Address - Fax:808-934-9442
Practice Address - Street 1:56 WAIANUENUE AVE
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-2474
Practice Address - Country:US
Practice Address - Phone:808-934-7566
Practice Address - Fax:808-934-9442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-08
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIW4094131601251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI24819201Medicaid