Provider Demographics
NPI:1851836589
Name:CHANGE PSYCHOLOGY CENTER
Entity Type:Organization
Organization Name:CHANGE PSYCHOLOGY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:WIEBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-366-3780
Mailing Address - Street 1:4134 CAMBOT CT NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49534-1100
Mailing Address - Country:US
Mailing Address - Phone:616-366-3780
Mailing Address - Fax:
Practice Address - Street 1:5304 ALPINE AVE NW
Practice Address - Street 2:
Practice Address - City:COMSTOCK PARK
Practice Address - State:MI
Practice Address - Zip Code:49321-9708
Practice Address - Country:US
Practice Address - Phone:616-366-3780
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-04
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015319251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health