Provider Demographics
NPI:1841743762
Name:THE LIFE CHANGE CENTER
Entity Type:Organization
Organization Name:THE LIFE CHANGE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:FIRESTONE
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LADC
Authorized Official - Phone:775-499-5534
Mailing Address - Street 1:1755 SULLIVAN LN
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89431-2815
Mailing Address - Country:US
Mailing Address - Phone:775-499-5534
Mailing Address - Fax:775-499-5535
Practice Address - Street 1:1201 N STEWART ST STE 120
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89706-3004
Practice Address - Country:US
Practice Address - Phone:775-350-7250
Practice Address - Fax:775-499-5535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-27
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV8312NTC-01103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Single Specialty