Provider Demographics
NPI:1134718042
Name:CHANGE THERAPEUTIC SERVICES, INC.
Entity type:Organization
Organization Name:CHANGE THERAPEUTIC SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAREELA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-654-0798
Mailing Address - Street 1:15447 ANACAPA RD STE D102
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-2481
Mailing Address - Country:US
Mailing Address - Phone:909-654-0798
Mailing Address - Fax:800-915-8151
Practice Address - Street 1:15447 ANACAPA RD STE D102
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-2481
Practice Address - Country:US
Practice Address - Phone:090-965-4079
Practice Address - Fax:800-915-8151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty