Provider Demographics
NPI:1952681504
Name:CENTER FOR LIFE CHANGE
Entity Type:Organization
Organization Name:CENTER FOR LIFE CHANGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MARRIAGE AND FAMILY THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:EILEEN
Authorized Official - Last Name:GROVES
Authorized Official - Suffix:
Authorized Official - Credentials:MMFT
Authorized Official - Phone:219-866-7869
Mailing Address - Street 1:1103 EAST GRACE STREET
Mailing Address - Street 2:BUILDING 2
Mailing Address - City:RENSSELAER
Mailing Address - State:IN
Mailing Address - Zip Code:47978
Mailing Address - Country:US
Mailing Address - Phone:219-866-7869
Mailing Address - Fax:219-866-0688
Practice Address - Street 1:1317 15TH ST SE
Practice Address - Street 2:
Practice Address - City:DEMOTTE
Practice Address - State:IN
Practice Address - Zip Code:46310-9393
Practice Address - Country:US
Practice Address - Phone:219-987-3719
Practice Address - Fax:219-987-7729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-26
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201049690AMedicaid