Provider Demographics
NPI:1962005108
Name:CHANGE ACADEMY AT LAKE OF THE OZARKS
Entity Type:Organization
Organization Name:CHANGE ACADEMY AT LAKE OF THE OZARKS
Other - Org Name:EMBARK AT THE FORGE
Other - Org Type:Other Name
Authorized Official - Title/Position:VP OF REVENUE CYCLE MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:J
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:661-829-4060
Mailing Address - Street 1:5500 MING AVE STE 410
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93309-4631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5842 HIGHWAY 30
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:TN
Practice Address - Zip Code:37307-4734
Practice Address - Country:US
Practice Address - Phone:505-205-5819
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHANGE ACADEMY AT LAKE OF THE OZARKS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-11-19
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children